Training programme

Title: Training programmeDeliverable n°: D.T1.2.1 Author: University of Primorska in collaboration with ASL Citta di

Torino, Regione Piemonte, Regione Liguria, CD Var, AKL.

Date: January 2017Version: 1.2

Contents

1. Objective of the Training programme............................................................................................4

2. Context...........................................................................................................................................4

3. Alpine Space programme...............................................................................................................4

4. Overall project objectives...............................................................................................................6

5. Preparation of the proposal for the implementation of education programmes in each country. 7

5.1 Community and family nursing as defined by the World Health Organisation.............................7

5.2 The needs of the older adults living at home...............................................................................9

6. Definition of the CoNSENSo Community Family health nurses supporting elderly Model...........11

6.1 Basis of embodiments home visits of elderly (simulation home visit)...................................................16

6.1.1. Healthy elderly...................................................................................................................16

6.1.2. Chronic disease/ long term care elderly refusing health care.............................................18

6.1.3.Elderly requiring long-term care–Elderly living with his/her spouse, treated after the fall (hip and knee surgery), not oriented in time and space...............................................................20

7. Process of the preparation of the training for Co.N.S.E.N.So nurses............................................22

8. The basis for the design of the training for Co.N.S.E.N.So nurses................................................23

8.1. Purpose and aim of the training................................................................................................24

8.2. Family and Community Nurse competences for the care of older adults..................................24

8.3. Needs defined by project partners............................................................................................25

9. The recommended method for implementing the programme...................................................26

10. The title: Family and community nursing for older adults........................................................28

11. Proposal for e-learning topics...................................................................................................31

10.1 The proposal of e-learning topics in this document will be suggested for the future study programme.......................................................................................................................................31

10.1.1 Regulation..........................................................................................................................31

10.1.2. Legal basis of public health...............................................................................................34

10.1.3 Support for older people outline.......................................................................................35

12. The Social Business Model........................................................................................................40

12.1. Training objectives and contents.............................................................................................41

12.2. Training structure.............................................................................................................42

12.3. Feedbacks from the field..................................................................................................45

13. Training report and evaluation.................................................................................................46

14. Training activities performed by each country partner individually.........................................50

15. References................................................................................................................................57

16. Appendix..................................................................................................................................58

Appendix 1: Five-day training to the extent of 45 hours, carried out in Slovenia for all Co.N.S.E.N.Sonurses involved in the project implementation................................................................................58

Appendix 2: Training Programme Certificate of Attendance............................................................59

Appendix 3: Annex to the Certificate of Attendance........................................................................61

Appendix 4: Training programme in Italy.........................................................................................62

Appendix 5: Training programme in Austria.....................................................................................66

Appendix 6: Training programme in France.....................................................................................72

Appendix 7: Training programme in Slovenia...................................................................................88

1. Objective of the Training programme The objectives of the Training programme are:

Create a training model for Co.N.S.E.N.So nurses with a uniform content proposal Propose policies for Training for Co.N.S.E.N. So nurses method Description references for common guidelines and e-learning platform to be

developed.

2. Context

Co.N.S.E.N.So projectThe Co.N.S.E.N.So project “COmmunity Nurse Supporting Elderly iN a changing SOciety” aimsto develop a care model that puts the older adults at the centre of health and social services,building on the crucial role of the family and community nurses. The project will focus onimproving and promoting human relationships to allow the older adults to live at home aslong as possible. The project partners will not only develop a specific training for nurses, work on newbusiness models, but will pilot a social and health care model in five areas in the AlpineSpace territory. The implementation of new public policies around this social innovation model is expectedto be the main result of the project.

3. Alpine Space programme

The Alpine Space programme connects actors from various sectors and different policy levelsfrom the programme’s 7 countries. They cooperate to tackle common challenges, exchangeideas and develop new working methods, with the aim of influencing policy-making. Sharingtheir experiences and expertise they work towards improving the quality of life for 66 millionpeople in one of the most unique areas of Europe. Actions supported by the programmehelp to make the Alpine Space more innovative, CO2-friendly, better connected and theycontribute to an improved governance.The programme is financed through the European Regional Development Fund (ERDF) aswell as through national public and private contributions of the partner states. Projects canbe co-financed through ERDF at a rate of up to 85%. For the 2014-2020 period, the totalbudget is €139 million.

Project partners The project brings together 10 partners from 4 Alpine Space countries (Austria, France, Italy,and Slovenia) and 7 observers representing governmental ministries, health authorities andprofessional associations from the Alpine Space area. The project leader is the HealthDepartment of the Piedmont Region.

PartnersAustria France Italy Slovenia

Project lead

Observers

4. Overall project objectives

People are living longer and most of them wish to grown old in their own homes. However,housing is often not adapted for the older adults needs, and public health and social servicesare limited in remote rural and isolated areas. This is particularly the case in the Alpine spacezone. The main idea behind the Co.N.S.E.N.So project is therefore to create conditions toimprove health and life quality enabling the older adults to stay at home. This could beachieved through the development of a new model of care for senior citizens based on theFamily and Community Nurse contribution in the Primary Care. Moreover, the project willwork towards three specific objectives:

Building, through training, an innovative model for health & social care for seniorcitizens

Evaluating in 5 pilot areas the new model for health & social care for senior citizens Building capacity for entrepreneurship through stimulating social enterprise

development by nurses.

The Training Report is prepared on the basis of the training week programme performed inIzola between 27 June and 1 July 2016 and on the training activities performed by eachcountry partners.

5. Preparation of the proposal for the implementation of educationprogrammes in each country

5.1 Community and family nursing as defined by the World HealthOrganisation

Traditional curricula at undergraduate level do not equip health professionals with therequired knowledge to care for ageing people and consequently with the skills to consider intheir daily activity effective preventive interventions (Bardach & Rowles 2012).

Co.N.S.E.N.So project accepts the challenge by developing a care model that puts the olderadults at the centre of health and social services. It builds on the pivotal role of the Familyand Community Nurse (FCN). The FCN plays an innovative role, linking health and socialservices with older people, their families and communities, becoming a key actor whoshapes and manages personalised services for the community dwelling older adults and theirfamilies, particularly those living in isolated areas. The training programme should thereforefocus on the development of competences, skills and knowledge to support older adults tolive in their home as long as possible. Nurses should be trained to perform home visits toassess health conditions, evaluate risk factors, manage minor health and social needs andpromote healthier lifestyles.

This is the focus in which we built the idea.

The first question that we have set ourselves in the process of the development of thetraining programme was: Which knowledge, skills and competences family andcommunity nurses need to perform their role in the care of older adults?

The first part of the answer is in the roles, tasks and competences of community and familynursing as defined by the WHO Regional Office for Europe for the Family Health Nurse .

WHO Regional Office for Europe (1999) in the document "HEALTH21: The health for all policyframework for the WHO European Region" states that a well trained Family Health Nurse(FHN) " can help individuals and families to cope with illness and chronic disability, or duringtimes of stress, by spending a large part of their time working in patients’ homes and withtheir families. Nurses give advice on lifestyle and behavioural risk factors, as well as assistfamilies with matters concerning health. Through prompt detection, they can ensure thatthe health problems of families are treated at an early stage. With their knowledge of publichealth and social issues and other social agencies, they can identify the effects ofsocioeconomic factors on health and refer them to the appropriate agency. They canfacilitate the early discharge of people from hospital by providing nursing care at home, andthey can act as the lynchpin between the family and the family health physician, substitutingfor the physician when the identified needs are more relevant to nursing expertise." (p 139).The platform of FHN is the bio-psycho-socio-cultural model of health. Findelstein (2015)

refers to the definition of health by the ICF (International Classification of Functioning,Disability and Health), which states that "health is experienced by people in their everydayenvironment where they learn, work, play and love". The author stresses that health is notjust the presence or absence of bodily functions; it is reflected in everyday activities and inthe social environment. Through education we can create a healthier living environment inwhich the physical and social dimension enables welfare and prosperity of its inhabitants(Findelstein, 2015). The priority of the FHNs work is not curative in its nature, but it ispreventive. Health promotion and disease prevention focused on individuals and theirfamilies is the core focus of the FHN (Hennessy & Gladin, 2006).

HEALTH21 points out that “families” (households) are the basic unit of society where healthcare providers will not only be able to address patients somatic physical complaints, but alsotake into account the psychological and social aspects of their condition. It is important forPrimary Helath Care providers to know the circumstances in which patients live: theirhousing, family circumstances, work, and social or physical environment, which may all havea considerable bearing on their illness (Ljubič, 2015). The FHN concept is based on the ideaof the ‘family unit’, which may include (Ljubič, 2015):

Individuals with geographically distant relatives; Friends who provide a supportive role in a similar way to a family member; A traditional nuclear family, with different generations being geographically close.

The core competencies of the family health nurses will be achieved through a process ofdeveloping the following competencies:

identify and assess the health status and health needs of individuals and familieswithin the context of their cultures and communities;

make decisions based on ethical principles; plan, initiate and provide care for families within their defined caseload; promote health in individuals, families and communities; apply knowledge of a variety of teaching and learning strategies with individuals,

families and communities; use and evaluate different methods of communication; participate in disease prevention; coordinate and manage care, including that which they have delegated to other

people and personnel; systematically document their practice; generate, manage and use clinical, research-based and statistical information (data)

for planning care and prioritizing health- and illness-related activities; support and empower individuals and families to influence and participate in

decisions concerning their health; set standards and evaluate the effectiveness of family health nursing activities; work

independently and as members of a team; participate in the prioritization of health-and illness-related activities;

manage change and act as agents for change; maintain professional relationships and a supportive collegiate role with colleagues; and display evidence of a commitment to lifelong learning and continuing

professional development (WHO, 2000).

The WHO vision of the FHN is: a multi-skilled generalist working as a coordinator of thedifferent health and social care professions in a multidisciplinary team (Hennessy & Gladin,2006) within home environments, families, across the lifecycle and within definedgeographical areas. As a key professional, together with the (family) physician, FHN wouldgive advice on lifestyle and risk factors, assist families with matters concerning health andillness, and take a proactive approach to health promotion, disease prevention, and earlydisease detection in the family environment (WHO, 2006). They would work in partnershipwith families, communities and other health professionals, acting as a health resource, bekey health promoters in society and facilitate co-operation between the family, thecommunity and the health care system (Hennessy & Gladin, 2006). FHN is perceived to havean important role throughout the course of life, at critical periods and life events, ensuringaccess to health care for all members of the community. They work in partnership withfamily physicians, ideally being a family’s first point of contact with the health services, andserving as the link between the family and the physician, the social services and theresources of the communities (WHO, 2000; Macduff, 2006).

5.2 The needs of the older adults living at homeThe World Health Organization (WHO) has prepared an action plan for healthy aging inEurope for the period 2012 - 2020. The vision of this strategy is based on an age-friendlyEuropean Region (WHO), where ageing is seen as an opportunity rather than a burden tosociety. This vision is based on the fact that the older adults are able to maintain theirhealth, that are functionally capable, they feel good and live a decent life, withoutdiscrimination and with adequate financial resources in a safe, supportive environment,enabling them to have an active life, be socially included and have access to appropriatehigh-quality health and social services. Age-friendly European Region WHO helps the olderadults to ageing in better health and to actively live according to their different roles, with afocus on employment and voluntary work (Strategy and action plan for healthy ageing inEurope 2012-2020, 2012). In 2012 The European Commission launched the European Innovation Partnership on Activeand Healthy Ageing (EIPonAHA) to find a way to tackle the population ageing. The triple aimsof the programme are: to enable EU citizens to lead healthy, active and independent liveswhile ageing; to improve the sustainability and efficiency of social and health care systems,and to boost and improve the competitiveness of the markets for innovative products andservices (EIPonAHA, 2012).

According to Kaučič, Filej and Ovsenik (2016), we need a new strategy in health care andquality of life of the older adults in Europe. There are four strategic priority areas for actionthat are complementary to each other and connected with other strategies and action plansof the WHO (see. Action Plan for Implementation of the European Strategy for thePrevention and Control of Non Communicable Diseases 2012-2016, 2011). The older adultsare often confronted with obstacles, such as the approach to high-quality health and long-term care, inadequate information and a high proportion of health care expenditure. Manyhealth care systems have to confront the challenges of how to solve the problem of agediscrimination, the integration of human sources and public funds. Special attention is paidto the training of a certain number of medical personnel with adequate knowledge ofgeriatrics and gerontology (Strategy and action plan for healthy aging in Europe 2012-2020,2012). According to Ramovš (2015), the quality of life of the older adults is affected by many

factors, among which family care during illness and functional decline plays a very importantrole. Kodrič (2014) states that before the modern form of the family, social care for the olderadults was provided (vertically) by the extended family. Ramovš (2015) argues that in thelast decade many countries with a long-standing legislation in the field of long-term carehave been expanding programmes for family caregivers. Zupancic (2012) states that theintegral care is an organized system of activities based on the needs of the people with areduced level of self-sufficiency, taking into account the resources of the local communityand in accordance with national guidelines. He states that it is a system that builds a networkof different providers and appoints a key person – coordinator in order to guarantee acomprehensive fulfilment of patient's needs, especially in their home environment. At thesame time, the person is provided with choices at all levels. Ramovš (2015) says that todayall over the developed world, the institutionalized care of the physical, mental or socialchronically ill, the age wearied and disabled people shows rapid development in new modelsthat take their care back to a freer and more responsible coexistence in the community. Thedeinstitutionalization of long-term care in the European countries started to develop quickerwhen they started to prepare and adopt national systems and legislation of developmentand the sustainable functioning of modern long-term care. The WHO (2017) warns that themajority of health and social care professionals has not the required knowledge and skills tointervene, promote health and prevent disease in older peopleSystematic care for the older adults living at home, must take into account the wholecontext in which the odler adults live. The figure below shows the model of community andfamily nursing for the treatment of older adults living in their home environment, which isbased on the understanding of the context of life of the older as an open system. Thescheme presented in Figure 1 is developed upon the open system of community familynursing of older developed by authors Maurer and Smith (2013).

Figure 1: A system approach to community family nursing for older adults living at homeSource: Maurer and Smith 2013

6. Definition of the CoNSENSo Community Family health nurses supportingelderly Model

Figure 1: The theoretical model Community Family health nurses supporting elderlyModel

In the following two pages the model of Community Family (hereafter C&H) Health NursingModel tha will be performed during the project is described. The Model defines three coresteps:

1ST STEP: TEST OF THE MODEL GROUPDuring the first visit the C&F Nurse will perform elderly health status assessment. Thisincludes gathering data from three sources: 1. Collecting data from other sources: where possible the nurse will gather data from accessible medical files;2. Collecting data during the visit: The C&F Nurse will evaluate the personal & family elderlyhealth parameters. Data will be gathered personally (elderly household) or the datacollection will be organised on a group level (in the local community). The type of data to begathered will be defined in the Consenso table App (to be presented during the training:Suggested conceptual data model for the CONSENSO App.). Two main approaches to datacollection will be applied: (i) proposed questionnaires (CONSENSO UP FVZ Group, 2016©); (ii)physical test (screening). Tools battery includes the following questionnaires:1. Demographic data2. Nursing History 3. Medical history 4. Social and Family History 5. WHOQOL – BREF ©1 6. EDMONTON FRAIL SCALE ©2The first four questionnaires (Demographic data; Nursing History; Medical history; Social andFamily History) will serve as a source for personal & family history data; the last twoquestionnaires (WHOQOL – BREF ©1; EDMONTON FRAIL SCALE ©2) will serve as a source forevaluation of the project on the micro (personal) level to be compared with the controlgroup. We propose the following physical tests (screening): height; weight; BMI; waist (cm);ECG; fasting blood sugar value (mmol/l); blood sugar value after a meal or any time duringthe day (mmol/l); blood pressure; blood fat level; Spirometry; Doppler, and Mini NutritionalAssessment©3.

2ND STEP: CONTROL GROUPThe control group will be questioned twice (with WHOQOL – BREF ©; EDMONTON FRAILSCALE ©): start of the model testing and in the end.

3RD STEP: COMMUNITY FAMILY NURSING PLAN & ACTION IMPLEMENTATIONOn the basis of gathered data C&F Nurse will prepare an individual nursing plan according tothe elderly classification: (I) healthy elderly, (II) elderly with health risk factors, (III) elderlywith chronic disease, (IV) elderly in long term care. There are two nursing plans possible:raising community awareness and further community family nursing plan & action.

For the purposes of the comparison of data between the test and the control group, theC&F Nurse will once more (as during the first visit) evaluate the personal & family elderly

1 WHOQOL Group. Development of the World Health Organization WHOQOL-Bref quality of life assessment. Psychol Med 1998; 28:551–558.2 Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing 2006;35:526–529.

3 Mini Nutritional Assessment (Mna): Research and Practise in the Elderly, 1999. Editor(s): B. Vellas, P.J. Garry, Y. Guigoz; NNI WorkshopSeries; vol. 01: https://www.nestlenutrition-institute.org/resources/library/Free/workshop/Publication00059/Pages/publication00059.aspx

health parameters: Nursing History; Medical history; Social and Family History; WHOQOL –BREF ©; EDMONTON FRAIL SCALE ©).

4TH STEP: PROJECT EVALUATIONThe final step in the model testing will be the evaluation of the overall results of the C&FNurses actions and activities.

Figure 2: Community family health nurses supporting senior citizens: model testing (1st

part)

Figure 3: Community family health nurses supporting senior citizens: model testing (2nd

part)

6.1 Basis of embodiments home visits of elderly (simulation home visit)

6.1.1. Healthy elderly

Nurses preparation for a home visit:- car, bag, tablet PC, phone, contact card, identification card, paper, pen.In the bag:- blood pressure monitor, oxygen meter, blood glucose monitor, portable scale, measuringtape, portable spirometer, Doppler with three sleeves, two sight test charts (for testing Hyperopia /farsightedness and myopia/nearsightedness), manual dynamometer, the cone for balance test, Rydel-Seiffer tuning fork (foot vibration test), portable ECG, scales (Quality of life - WHOQOL) for screening and evaluation Before the visit:

- check the battery of the tablet PC and of the phone

Before the visit the nurse checks whether the necessary data (of the elderly and of the location) are included in the App. (tablet PC): - ID code, name and surname, middle name, date of birth, address, zip code, telephone number of the elderly, the telephone number of the contact person, name and surname of the contact person

Nurse should be aware that the home visit most often will not be unannounced. For the elderly the visit can be also undesirable. Therefore the nurse should:- first present herself/himself and show the identification card- explain the purpose of the visit- present herself/himself to all family members (especially during the first visit)- be polite

Caution:- if s/he is hears well- if s/he sees well- if s/he understands what the nurse explains (cognitive capacity and possible changes)

IMPORTANT- Nurse establishes a partnership relation with the elderly

FIRST STEPBasic questions - Option 1:- ID, country, code, explanation of the possibility to refuse the visit (date, reasons for refusal), the elderly refuses the visit – the end of the visit

Basic questions - Option 2:- ID, country, code, gender, date of birth, marital status (date change), with whom he lives in the household (date change), the living area, education – the highest level of school completed, work experience, type of the living environment, number of children… (Data gather through tablet PC) – Continuation of the visit (go to the second step).

SECOND STEPHistory:- medical history: details on previous diseases (diabetes, arterial hypertension, stroke, ...),

- information on previous (last 6 months) hospitalizations,- nursing history: the symptoms (visual disturbances, dizziness, insomnia, chronic pain,

scales),- family history: disease in the family (cancer, heart disease, diabetes, ..),- social history: economic status (source of livelihood), bad habits (smoking, alcohol, ..)

THIRD STEPMeasurements:- measure blood pressure, measure pulse and assess the pace and quality of the pulse, measure oxygenation, measure weight and height, determine BMI, measure waist circumference, measure glucose level

STEP FOURQuestionnaires on the tablet PC:- the first part: physical activity- the second part: knowledge an utilization of available community resources for care; Functional capacity of the older adult (related to basic life activities), Involvement in social activities - the third part: Perceptions of social ties and networks

STEP FIVE

Questionnaires on the tablet PC:- performs evaluation tests: Frailty test, Quality of life scale

CONCLUSIONElderly Counseling:- advice about activities supporting and promoting health (health education), Contact card:- the elderly should be informed that s/he can call the nurse at any timeVisit over 18 months:- the elderly should be informed that the visit will be repeated over a period of 18 months

6.1.2 Chronic disease/ long term care elderly refusing health care Nurses preparation for a home visit:- car, bag, tablet PC, phone, contact card, identification card, paper, pen.In the bag:- blood pressure monitor, oxygen meter, blood glucose monitor, portable scale, measuringtape, portable spirometer, Doppler with three sleeves, two sight test charts (for testing Hyperopia / farsightedness and myopia/ nearsightedness), manual dynamometer, the cone for balance test, Rydel-Seiffer tuning fork (foot vibration test), portable ECG, scales (Quality of life - WHOQOL) for screening and evaluation Before the visit: - check the battery of the tablet PC and of the phone

Before the visit the nurse checks whether the necessary data (of the elderly and of the location) are included in the App. (tablet PC): - ID code, name and surname, middle name, date of birth, address, zip code, telephone number of the elderly, telephone number of the contact person, name and surname of the contact person

Nurse should be aware that the home visit most often will not be unannounced. For the elderly the visit can be also undesirable. Therefore the nurse should:- first present herself/himself and show the identification card - explain the purpose of the visit - present herself/himself to all family members (especially during the first visit); - be polite

Caution:- if s/he hears well- if s/he sees well- if s/he understands what the nurse explains (cognitive capacity and possible changes)

IMPORTANT- Nurse establishes a partnership relation with the elderly

FIRST STEPBasic questions - Option 1:- ID, country, code, explanation of the possibility to refuse the visit (date, reasons for refusal), the elderly refuses the visit – the end of the visit

Basic questions - Option 2:- ID, country, code, gender, date of birth, marital status (date change), with whom s/he lives in the household (date change), the living area, education – the highest level of school completed, work experience, type of the living environment, number of children… (Data gather by tablet PC) – Continuation of the visit (go to the second step).

SECOND STEPHistory:- medical history: details on previous diseases (diabetes, arterial hypertension, stroke, ...), - information on previous (last 6 months) hospitalizations,- nursing history: the symptoms (visual disturbances, dizziness, insomnia, chronic pain, scales),- family history: disease in the family (cancer, heart disease, diabetes, ..),- social history: economic status (source of livelihood), bad habits (smoking, alcohol, ..)

THIRD STEPMeasurements:- measure blood pressure, measure pulse and assess the pace and quality of the pulse, measure respiratory rate, observe depth of breathing, observe deviations in breathing, measure oxygenation, observe the color of the mucous membranes and skin, measure weight and height, determine BMI, measure waist circumference, measure glucose level, determine skin temperature - hot, cold, clammy, skin turgor, observe the jugular vein for possible jugular vein pressure

STEP FOURQuestionnaires on the tablet PC:- the first part: physical activity- the second part: knowledge an utilization of available community resources for care; Functional capacity of the older adult (related to basic life activities), Involvement in social activities - the third part: Perceptions of social ties and networks

STEP FIVE

Questionnaires on the tablet PC:- perform evaluation tests: Frailty test, Quality of life scale Measurements: - Perform spirometry, ECG, perfusion test - Doppler test, Mini Nutritional Assessment test

CONCLUSIONHealth education:- advice elderly on the need to change his/ her lifestyle: limiting alcohol and smoking, weight reduction, reducing salt intake (max. 5g/ day), consumption of wholegrain products, increasing physical activity (3 to 4 times a week for 30 to 45 minutes)- educate the elderly on how to regularly monitor the blood pressure: nurse performs the demonstration and stresses the need for precise measurements and regular recording of the measurement values- advise the elderly to get involved in different national programs of primary prevention organized by Health educational centers and NGOs: CINDI, schools for weight loss...- present various forms of home assistance: social care, community nursing - the elderly should be informed that s/he can call the nurse at any time- the elderly should be informed that the visit will be repeated over the period of 18 months

6.1.3 Elderly requiring long-term care–Elderly living with his/her spouse, treatedafter the fall (hip and knee surgery), not oriented in time and space

Nurses preparation for a home visit:- car, bag, tablet PC, phone, contact card, identification card, paper, pen.In the bag:- blood pressure monitor, oxygen meter, blood glucose monitor, portable scale, measuringtape, portable spirometer, Doppler with three sleeves, two sight test charts (for testing Hyperopia / farsightedness and myopia/nearsightedness), manual dynamometer, the conefor balance test, Rydel-Seiffer tuning fork (foot vibration test), portable ECG, scales (Quality of life - WHOQOL) for screening and evaluation Before the visit:

- check the battery of the tablet PC and of the phone

Before the visit the nurse checks whether the necessary data (of the elderly and of the location) are included in the App. (tablet PC): - ID code, name and surname, middle name, date of birth, address, zip code, telephone number of the elderly, telephone number of the contact person, name and surname of the contact person

Nurse should be aware that the home visit most often will not be unannounced. For the elderly the visit can be also undesirable. Therefore the nurse should:- first present herself/himself and show the identification card - explain the purpose of the visit

- present herself/himself to all family members (especially during the first visit);

- be polite

Caution:- if s/he hears well- if s/he sees well- if s/he understands what the nurse explains (cognitive capacity and possible changes)

IMPORTANT- Nurse establishes a partnership relation with the elderly

FIRST STEPBasic questions - Option 1:- ID, country, code, explanation of the possibility to refuse the visit (date, reasons for refusal), the elderly refuses the visit – the end of the visit

Basic questions - Option 2:- ID, country, code, gender, date of birth, marital status (date change), with whom s/he lives in the household (date change), the living area, education – the highest level of school completed, work experience, type of the living environment, number of children… (Data gather by tablet PC) – Continuation of the visit (go to the second step).

SECOND STEPHistory:- medical history: details on previous diseases (diabetes, arterial hypertension, stroke, ...),

- information on previous (last 6 months) hospitalizations,- nursing history: the symptoms (visual disturbances, dizziness, insomnia, chronic pain,

scales),- family history: disease in the family (cancer, heart disease, diabetes, ..),- social history: economic status (source of livelihood), bad habits (smoking, alcohol, ..)

THIRD STEPMeasurements:- measure blood pressure, measure pulse, measure oxygenation, measure weight and height, determine BMI, measure glucose level

STEP FOURQuestionnaires on the tablet PC:- the first part: physical activity- the second part: knowledge an utilization of available community resources for care; Functional capacity of the older adult (related to basic life activities), Involvement in social activities

- the third part: Perceptions of social ties and networks

STEP FIVE

Questionnaires on the tablet PC:- performs evaluation tests: Frailty test, Quality of life scale

Measurements:

- Performs spirometry, ECG, sight test, muscle strength test, balance test, Rydel-Seiffer tuning fork (foot vibration test), dementia test

CONCLUSIONElderly and family counseling: - educate the elderly and the family members (if applicable) on falls and injuries prevention - advice on possibilities to include the elderly in long-term care network - inform the elderly and the family members about available forms of health and social care - the elderly should be informed that s/he can call the nurse at any time- the elderly should be informed that the visit will be repeated over the period of 18 months

7. Process of the preparation of the training for Co.N.S.E.N.So nurses

In the initial phase of the Co.N.S.E.N.So project the project partners PP7 and PP2, developeda draft model Training programme for all the countries involved in the CO.N.S.E.N.SOproject. Basically, we divided the education into two parts for the period of 2016:

A five-day training to the extent of 45 hours, carried out in Slovenia for allCo.N.S.E.N.So nurses involved in the project implementation (Appendix 1). Finishedby 1 July 2016 with a receipt of a Training Programme Certificate of Attendance(appendix 2) and of a Certificate with the number of study hours transformed intoECTS (appendix 3).

The training is designed as a post-graduate education programme for nurses that iscarried out in each country according to local rules and opportunities (Appendix 2).

In the following years until 2018, the complete training for nurses of Co.N.S.E.N.So will becomplemented by:

The Family and community nursing training, The e-learning platform The social business planning and modeling.

The instructions of the leading partner on the education of the Co.N.S.E.N.So. nurses were tocarry out the education within each country according to the local policies. The performedtraining programme by participating countries are presented in the appendixes (Italy(appendix 5), Austria (appendix 4), France (appendix 7), (appendix 8)). The hours can, by therules of the Bologna system, be converted into credits and are considered in the validationof the lifelong learning and the acquisition of certificates about the completion of apostgraduate education.

8. The basis for the design of the training for Co.N.S.E.N.So. nurses

The Co.N.S.E.N.So. training programme was developed on the bases of:

The documents that propose the competences that the nurses should gain with theundergraduate studies of nursing: the European Commission Directive 2013/55/EUthat amended the Directive 2005/36/EC; the European Federation of Nursesassociations EFN guidelines for implementation of the Article 31 on the mutualrecognition of professional qualifications, Brussels 2015; the Nursing and MidwiferyCouncil Standards of Competence for Registered Nurses;.

The Family Health Nurse Context, Conceptual Framework and Curriculum of theWorld Health Organization (WHO, 2000), a curriculum designed to prepare qualifiedand experienced nurses for the new role derived from the WHO definition of themultifaceted role of the Family Health Nurse.

The European Family Health Nursing Project (FamNrsE), funded by the EuropeanUnion Lifelong Learning in 2011 that was a revitalized World Health Organizationinitiative involving Armenia, Austria, Germany, Italy, Poland, Portugal, Romania,Slovenia, Spain and Scotland. The project lead to a definition of family health nursing,required core competencies and capabilities, and consequent education and trainingrequirements to tackle the global health challenges. A MSc In Family Health has beenlaunched in Scotland on the project results.

The International Council of Nursing (ICN, 2002) guidelines for the community andfamily nurse

Overview of the competences of nurses achieved through undergraduate studyprogrammes in some European countries.

The Master of Science In Family Health launched in Scotland at the end the EuropeanFamily Health Nursing Project (FamNrsE), funded by the European Union LifelongLearning in 2011 has also been considered to modulate the programme as aUniversity Master degree.

Overview of a postgraduate specialist study programme of nursing: o The Spanish Family and Community Nurses specialty programme, a 2-yearpostgraduate education to become a specialist in family and community nursing(Rocco et al 2017).o The PGD (Master of I level) of the University of Turin in Family and CommunityNursing delivering 60 ECTS that has been launched since 2005 and has beenrecognised as good practice by the European Commission programme EIPonAHAsince 2012.o The Austrian PGD in Family and Community Nursing delivering 90 ECTS.

o The Australian training study programme, developed by Hua Mei TrainingAcademy in Australia on Community Gerontological Nursing.

The comparison among the local implemented Co.N.S.E.N.So. training programmes inthe four Co.N.S.E.N.So. countries: Italy, Austria, France, and Slovenia.

The predicted competences that a community and family nurse older adults shouldhave, defined by project partners through the questionnaire prepared by PP7.

The Five day training for the Co.N.S.E.N.So. Nurses lead by the r University in Izola.

8.1. Purpose and aim of the training The basic aim of the training programme is to provide advanced education to the nurses inhealth care for the older adults. Specialist family and community nurses will be able tooperate independently in the community with the individuals and their families. Theparticipants in the training will gain in-depth knowledge in the field of health promotion,identification of risk factors, early detection of frailty in older adults, integration of care.They will acquire the competencies of case management, innovative strategies, andcommunity networking to support the well-being of older adults and the possibility to live intheir home as long as possible.

8.2 Family and Community Nurse competencies for the care of older adults

The competencies to perform of nursing care in Europe are recognised to nurses trainedaccordingly to the European Commission Directive 2013/55/EU (that amended the Directive2005/36/EC), the EFN (2015) guidelines for implementation of the Article 31 on the mutualrecognition of professional qualifications, the Nursing and midwifery Council Standards ofCompetence for registered nurses.

Therefore, the entry requirements for this study program is the bachelor study programmein Nursing, developed and implemented in accordance to the European CommissionDirective 2013/55/EU (that amended the Directive 2005/36/EC).

The general competences that a nurse acquires or deepens in the predicted postgraduateeducation are summarized from the ICN (International Council of Nurses - ICN) guidelines forcommunity and family nurse (2002):

Coordinating a territorial project Researching: identifying practice problems and seeking answers and solutions

through scientific investigation, early detection and management of frailty in older people, Identifying the needs and nursing problems of the older adults, their families and the

communities in which they live ; early detection and management of frailty in olderpeople, evaluation of the status of seniors living at home,

Health promotion and education of the elderly and their families (formally orinformally) about health and illness; acting as the main provider of healthinformation,

Care providing and supervising: providing direct care and supervising care given byothers, including family members, nursing assistants and other professionalsaccording to the needs of the older adults,

Older adults and family advocating: working to support older adults and families anddiscussing issues such as safety and access to services,

Case finding and epidemiology: tracking disease and playing a key role in diseasesurveillance and control.

Management and coordination: managing, collaborating and liaising with familymembers, health and social services and others to improve access to care.

Counselling: playing a therapeutic role in helping to cope with problems and toidentify resources, creating therapeutic relationship,

Consulting: serving as consultant to older adults and families and agencies to identifyand facilitate access to resources.

Environmental modification: working to modify, for example, the home environmentso that the older adults can improve their mobility and engage in self-care.

8.3. Needs defined by project partners

The Project Partner (PP) 7 developed an e-questionnaire to gather input from the ProjectPartners on nurses’ educational needs to successfully perform the Co.N.S.E.N.So care model(older adults care at home). The table presents training needs as defined by PPs. As definedby PPs, the core competencies needed for the nurses are: Family and Individual CentredNursing; Assessment Tools; Health Prevention and Health Promotion, TherapeuticRelationship.

Austria The four key (basic) contents for nurses carrying out the Co.N.S.E.N.So caremodel are:- Family Centred Nursing;- Assessment Tools;- Public Health Focused On Families;- Health Promotion and Prevention.

The four key contents for a successful execution of the project are:- Structure of the Health System;- E-Health;- Caregiver Burden and Coping Strategies;- Law (social and health).

Italy The four key (basic) contents for nurses carrying out the Co.N.S.E.N.So. caremodel, which are also stressed as key contents for a successful execution of theproject, are:Therapeutic relationship;Counselling;Health Promotion;Case Management.

France The basic idea (purpose and objectives) of the training programme in France isbased on the achievement of the three (basic) competencies for nurses carryingout the Co.N.S.E.N.So. care model in their country:Coordinating a territorial project;

Evaluate the situation of the senior at home;Developing an educational posture.

To develop these competencies, the action training was entrusted to theRegional Centre of Vocational Training (C.R.F.P.) of the French Red Cross. Theaforementioned training additionally includes:Project Coaching;Analysis of Professional Practices.

Slovenia The competencies that the graduate nurses will obtain in this training in order tocarry out the Co.N.S.E.N.So. care model are prepared on the background of theICN (2002) competencies model for family and community nurses Coordinating a territorial project;Research: Identifying practice problems and seeking answers and solutionsthrough scientific investigation alone or in collaboration, Early detection andmanagement of frailty in older people;Identifying the needs and nursing problems of the older adults, their families andthe communities in which they live, early detection and management of frailty inolder people, evaluate the situation of the senior at homeHealth promotion and education for older adults and their families (formal andinformal) about health care and illnesses, acting as the main provider of healthinformation;Care provider and supervisor: providing direct care and supervision of careprovided by others, including family members, nursing assistants and otherprofessionals according to the needs of the older adults;Older adults and family advocacy: Working to support older adults people andfamilies and talking about the issues such as safety and access to services; Case finder and epidemiologist: Tracking disease and playing a key role in diseasesurveillance and control;Management and coordination: Managing, collaborating and liaising with familymembers, health and social services and others to improve access to care;Counselling: Playing a therapeutic role in helping to cope with problems and toidentify resources, creation the therapeutic relationship;Consulting: Serving as consultant to older adults, their families and agencies toidentify and facilitate access to resources;Environmental modification: working to modify, for example, the homeenvironment so that the disabled can improve mobility and engage in self-care.

9. The recommended method for implementing the programme

The programme will be executed: Lectures up to 1/3 E-learning up to 1/3 Clinical training up to 1/3

Contents of the programme

The programme consists of core and optional modules. The content of the training isdeveloped in accordance to the general competences defined by ICN guidelines forcommunity and family nurse (ICN, 2002), and the training needs defined by project partners(the core needed nurses' competencies defined by project partners are: Family andIndividual Centred Nursing; Assessment Tools; Health Prevention and Health Promotion,Therapeutic Relationship).

The training programme is defined also in accordance with a comparative training/ studyprogramme, developed by Hua Mei Training Academy in Australia on CommunityGerontological Nursing. In accordance to the Hua Mei Training Academy, Community andfamily nursing taking care of older adults at their homes have a very specific workingenvironment and different home living conditions. A supportive care partnership should bebuilt with each home-dwelling older person, considering the personal family and communitycircumstances and resources, «which are fluid and unpredictable». Therefore, the trainingshould enable the nurses to perform primary and long-term care of older adults,independently, with the utilisation of a holistic approach, innovative strategies, and incooperation with the available health and social care services and informal resourcespresent in the community for supporting older adults.

The training programme consists of 4 modules. The first year includes two modules:

1. Core courses on primary care, community and family care and older adults care :mandatory courses give to nurses basic knowledge and skills on modern communitycare and care of older adults. The theoretical bases of the first module are upgradedby clinical practices in real-life situations of older adults care at home. The firstmodule consists of 30 ECTS.

2. Clinical practice in community and family nursing: The clinical practice moduledelivers 30 ECTS and it lasts from 4 to 6 months, depending on the daily workload ofstudents.

At the end of the year students achieve a Post Graduate Diploma in Family andCommunity nursing

The second year of training consists of two modules:

3. Elective contents: elective courses give to nurses specific contents in accordance to the national specific regulations and practices in health and social care of older adults. Students can choose 5 elective courses. The module consists of 30 ECTS.

4. Enquire and Dissertation module: In the last semester of the training/ study programme students prepare a final thesis. Depending on the national specific organisation of primary and nursing care and on the national specific system of nursing care education the finalisation of the study could be performed also as final examination (final exams). This module delivers 30 ECTS

At the end of the second year students achieve the Master of Science in Family and Community Nursing

The intended form of implementation the program is designed to carry out postgraduatestudies, which concludes with a master's thesis or specialist task modeled after thepreparation of the ECTS evaluation in Slovenia. The focus of the program is the specifiedcontent, which can be applied in different ways of studying and adapt to each schoollegislation in the European country where the program will be implemented.

The expected competences of the nurses that undergo this training programme are:

Identify the health and social needs of the older adults, their families and thecommunities in which they live

Identify practice problems and seeking answers and solutions through scientificinvestigation

Health promotion and health education for older adults and their families Early detection and management of frailty in older people Provide direct care and supervision of care provided by others, including family

members, caregivers, nursing assistants and other professionals and institutions. Coordinate a territorial project Working to support older adults and families. Serving as consultant to older adults, their families to identify and facilitate access to

services and resources. Assessing the living ambient and, in case, to modify the home so that the older adults

can improve their mobility and engage in self-care in a safe environment.

10.The title: Family and community nursing for older adults ECTS andCONTENTS

1st year ECTS

Core content: Public health, community andfamily nursing and older adults care

30

Mandatory content: Clinical practice in familyand community nursing

30

2nd year ECTS

Elective contents: Public health and communityand family nursing - elective courses 30

Final thesis or final examination 30

1st Year of training/study programme

ECTS (1 ECTS=30contact hours) CONTENTS

Mandatory contents: Public health, communityand family nursing andolder adults care

30

Health promotion andEuropean policies inhealthcare of thepopulation aged 65 ormore

6

The European health policy framework to supportaction across government and society to improvethe health and well-being of populations, strategyand action for healthy aging in Europe, WHO globalreport on non-communicable diseases, WHO globalaction plan for prevention and control of non-communicable diseases, international and nationalpublic health policies; activities supportingwellbeing and healthy ageing

Community and family 6 The family and community nurse role in the

nursing

primary care context; the social determinants ofhealth and their impact on people living in ruralareas; the nursing assessment: evaluation methodsand scales; the systemic reading of thecommunications in the family network: thegenogram; the narrative collection of people'shealth story; the case management; case studies ofintegrated care good practices; e-health for olderpeople and the ens4care guidelines.

Evidence-based practicesin community and familynursing

3

Literature search: definition, aims and methods,bibliographic databases; scientific journals; criticalreading of a scientific article; analysis of guidelines;systematic reviews and meta-analysis.

Social Medicine andEpidemiology 3

Historical notes on the development of theepidemiology; definition of epidemiology; thecause and effect relationship; accuracy andprecision of an epidemiological study; frequencymeasurements; the statistical significance.

Concepts and principlesof health promotion andhealth communication

6

Individual and family counselling; principles andmethods of health promotion, health educationand therapeutic patient education (TPE); theconstruction of a therapeutic education project;the psychological, organisational, social andcommunity empowerment; methods and tools forempowerment evaluation; methods and tools forimproving therapeutic adherence and resilience;self-help groups; home visiting first interview: toolsand methods; motivational interview; telephoneinterview and phone call follow-up; e-health tools.

Frailty in older adults.The prevention andmanagement ofcapacities decline andlong term diseases

6

Early detection, prevention and management ofthe frail condition in older people; multi morbidityand polypharmacy; the environment and the longterm diseases; the clinical pathways and guidelines: their use in the clinical practice; healthpromotion for physical activity and nutrition;smoking and excessive alcohol consumption; homesafety; home safety; the person affected bydementia; the person with respiratory diseases;the person with diabetic disease

Mandatory contents :clinical practice incommunity and familynursing

30

2st Year of training/study programme

ECTS (1 ECTS=30contact hours) CONTENTS

Students choose 5elective courses 30 ECTS Elective courses. The specific contents of the

elective courses should be defined in accordance to

the national specific regulations and practices inhealth and social care of elderly.

Health literacy and olderpeople 6Interculturalcommunication in healthcare 6

Long-term care andpalliative care for elderly 6Entrepreneurship andsocial businessmanagement 6

Holistic nursing care 6Health and socialinstitutions supportingolder adults 6

Healthy aging 6

Design of safeenvironment for elderly 6Older adults socialnetworks and theirimpact on quality of life 6

Family nursing in thecontext of elder care 6Family members as olderadults carers: the familyand community nursessupport 6

11.Proposal for e-learning topics

The Consenso platform (https://lms.consensoproject.eu/) has been structured and projectedby Accademia Nazionale di Medicina in order to be a valuable tool either for nurses or forpartners of CONSENSO project.

In fact, it has been designed as a storage instrument to collect e-learning contents (lectures,video, documents, presentations etc.), easily uploaded by teachers or tutors and to be at thesame time a repository for project documents. The basic structure is composed by a homepage where a user can choose its favourite language (Italian, German, Slovenian, French,English) and login with a personal ID. Through the access to the reserved part of theplatform, the user can have access to:

Personal page where documents or conversations can be stored and saved Nurse courses lectures and contents (uploaded by teachers or tutors)

General contents of the projects (meeting minutes, general documents, deliverablesand any other useful material.)

The forum. In particular, it is possible to the access to the local forum (involving localnurses) or the general forums, which involves all nurses from each country.

By choosing one of the above mentioned section, the portal opens a new page where theselected documents can be found. Moreover, it is always possible to start a forum byproposing a topic or participating to an existing one, y adding personal comment orcontribution.

After two years almost after the presentation of the platform at the Meeting in Izola, June2016, we have noticed that not every partner used this tool as a real useful workinginstrument. This because we found that some countries have their own repository platformfor e-learning contents, often linked to the University, and forces users/nurses to use it. Bythe way, the parters who directly use Co.N.S.E.N.So. platform express satisfaction on theusability, easiness, and functionality of it. The only part that did not worked was the forum.We tried to investigate on the reasons of this failure and nurses underlined that it would bebetter and easier to use (and as a consequence, more useful) to have directly on the app, notin the platform.Sometimes, they said, it would be nice to have in fact an immediate feedback from otherusers on a problem or situation while visiting an elder, without having to link to the portal,being not easy and quick.

From the project users point of view, the portal has been useful to collect all projectdocuments (minutes, lists, visibility identity material) in a single place, reducing theexchange of emails.

10.1 The proposal of e-learning topics in this document will be suggested forthe future study programme.

The e-content suggestions were created on the basis of a review of the design content forthe implementation of nursing education programmes in the countries involved in theproject (Austria, Italy, France and Slovenia). Proposal for e-content is divided into an threethematically different contents:

10.1.1 RegulationTitle Content e-link to document

GENERAL DECLARATION OFHUMAN RIGHTS

It means recognizing the innate humandignity of all members of human societyand their equal and inalienable rights, thefoundation of freedom and justice andpeace in the world.

http://www.ohchr.org/EN/UDHR/Documents/UDHR_Translations/eng.pdf

EUROPEAN CONVENTIONON THE PROTECTION OFHUMAN RIGHTS ANDFUNDAMENTALFREEDOMS

It provides everyone with equal humanrights and fundamental freedomsregardless of age as a personalcircumstance: allows older people toremain full members of society for as longas possible, allows older people to freelychoose their lifestyle and liveindependently in the home environmentfor as long as they want and can, with thehelp of: accommodation tailored to theirneeds and their state of health orappropriate assistance in adapting theiraccommodation; health care and servicesthey need according to their condition.

http://www.echr.coe.int/Documents/Convention_ENG.pdf

INTERNATIONAL PACT ONECONOMIC, SOCIAL ANDCULTURAL RIGHTS

The Pact obliges States Parties to provideeconomic, social and cultural rights.

http://www.ohchr.org/Documents/ProfessionalInterest/cescr.pdf

INTERNATIONAL PACT ONCITIZENSHIP ANDPOLITICAL RIGHTS

Everyone has the right to self-determination. With this right, they freelydetermine their political status and freelyprovide their economic, social and culturaldevelopment.

https://treaties.un.org/doc/publication/unts/volume%20999/volume-999-i-14668-english.pdf

EUROPEAN SOCIALCHARTER

The European Social Charter providessocial and economic human rights.

https://rm.coe.int/168048b059

FUNDAMENTAL

RIGHTS IN THE

EUROPEAN UNION

The Charter of Fundamental Rights sets outa wide range of rights, freedoms andprinciples, resulting in responsibilities andduties with regard to other persons, to thehuman community and to futuregenerations.

http://www.europarl.europa.eu/RegData/etudes/IDAN/2015/554168/EPRS_IDA(2015)554168_EN.pdf

LEGAL PROTECTION OFRIGHTS OF THE ELDERLY

It gives older people the right kind ofassistance that enables them to effectivelyprotect their rights. The European SocialCharter of the Council of Europeguarantees a range of rights that are ofgreat importance for the elderly and fortheir enjoyment of the right to healthcare.

https://social.un.org/ageing-working-group/documents/fourth/Rightsofolderpersons.pdf

10.1.2. Legal basis of public health

Title Content

INTERNATIONAL HEALTH REGULATIONS

Health and social services https://cursos.campusvirtualsp.org/pluginfile.php/33425/mod_resource/content/1/International%20Health%20Regulations.pdf

EU HEALTH PROGRAMME: WORKING TOGETHER TO IMPROVE PUBLIC HEALTH IN EUROPE

The role of WHO at promoting health policy. https://ec.europa.eu/health//sites/health/files/programme/docs/eahc_hp_working_together_en.pdf

THE ECONOMICS OF SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUALITIES: a resource book

The health of the individual depends on hislife style. Determinants of health constitute arange of personal, social, economic, andenvironmental factors.

http://apps.who.int/iris/bitstream/10665/84213/1/9789241548625_eng.pdf

2015 INTERNATIONAL PROFILES JANUARY 2016 OF HEALTH CARE SYSTEMS

PRIMARY HEALTH CARE AND PUBLIC HEALTH: FOUNDATIONS OF UNIVERSAL HEALTH SYSTEMS

Primary health care is the first point where anindividual comes into contact with thehealthcare system, where most of their healthneeds are met, but at the same time they arelike a door to the rest of the system. In thisregard, primary health care plays a key role inhow patients appreciate a health system thatresponds to their needs and expectations.

http://www.commonwealthfund.org/~/media/files/publications/fund-report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf

https://www.karger.com/Article/Pdf/370197.

WHO: MENTAL HEALTH ACTION PLAN 2013 - 2020

Mental Health Plan WHO 2013-2020. TheWorld Health Organization described the newAction Plan for Integrated Mental Health2013-2020 as a milestone: it focused oninternational attention on a long-standingproblem and is firmly anchored in humanrights principles. The Action Plan requireschanges. It calls for a change in relations tothe stigmatization and discrimination that hasbeen isolating people for a long time, and callsfor the expansion of services in order toencourage greater efficiency in the use ofresources.

http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf

MEDNARODNA KLASIFIKACIJA ZDRAVSTVENE NEGE (INTERNATIONAL CLASSIFICATION FOR NURSING PRACTICE - ICNP®)

It sets out an international standard tofacilitate the description and comparison ofnursing practice at local, regional, national,and international level.

http://www.icn.ch/what-we-do/icnp-download-redirection/

THE FAMILY HEALTH NURSE CONTEXT, CONCEPTUAL FRAMEWORK AND CURRICULUM

HEALTH21, the health policy framework forthe European Region of WHO introduces anew type of nurse, the Family Health Nurse,who will make a key contribution within amultidisciplinary team of health careprofessionals to attainment of the 21 targetsfor the twenty-first century set out in thatpolicy

http://www.euro.who.int/__data/assets/pdf_file/0004/53860/E92341.pdf

WHO FAMILY HEALTH NURSE

MULTINATIONAL STUDY

The WHO Family Health Nurse MultinationalStudy reflects the intention of the MunichDeclaration: Nurses and Midwives – a forcefor health to enhance the role of nursesparticularly in the field of public health. Theoutcomes of the Multinational Study on theFamily Health Nurse are intended to informpolicy-makers on the most effective way ofdeveloping community nursing and relatedservices in the future.

http://apps.who.int/

iris/bitstream/10665/

107486/1/E79369.pdf

COMMUNITY HEALTH NEEDS ASSESSMENT

This document describes the ways in whichhealth needs assessment can identify priorityhealth needs, target resources to addressinequalities and involve local people. Theprocess of undertaking health needsassessment is described and the importantcontribution of nurses explored. Thedocument also includes a pack for training thetrainers in the use of the assessment tool.

http://www.euro.who.int/__data/assets/pdf_file/0018/102249/E73494.pdf

10.1.3 Support for older people outlineDEMENTIA

WHAT IS:Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Dementia is not aspecific disease. It's an overall term that describes a wide range of symptoms associated with a decline in memory orother thinking skills severe enough to reduce a person's ability to perform everyday activities. SCREENING TESTS FOR DEMENTIA: The mini-mental state exam and the mini-cog test are two commonly used tests.Mini-mental state exam (MMSE)During the MMSE, a health professional asks a patient a series of questions designed to test a range ofeveryday mental skills. The maximum MMSE score is 30 points. A score of 20 to 24 suggests milddementia, 13 to 20 suggests moderate dementia, and less than 12 indicates severe dementia. Onaverage, the MMSE score of a person with Alzheimer's declines about two to four points each year.Mini-cog During the mini-cog, a person is asked to complete two tasks:Remember and a few minutes later repeat the names of three common objects. Draw a face of a clock showing all 12numbers in the right places and a time specified by the examiner. The results of this brief test can help a physiciandetermine if further evaluation is needed.TREATMENT:Medications: cholinesterase inhibitors, memantinTherapies: occupational therapy, modifying the environment, modifying tasksLifestyle and home remedies: enhance communication. encourage exercise. encourage activity. establish a night timeritual, encourage keeping a calendar, plan for the futureHere are some suggestions you can try to help yourself cope with the disease:Learn as much as you can about memory loss, dementia and Alzheimer's disease.Write about your feelings in a journal.Join a local support group.Get individual or family counselling.

Talk to a member of your spiritual community or another person who can help you with your spiritual needs.Stay active and involved, volunteer, exercise, and participate in activities for people with memory loss.Spend time with friends and family.Participate in an online community of people who are having similar experiences.Find new ways to express yourself, such as through painting, singing or writing.Delegate help with decision-making to someone you trust.Caregiver supportProviding care for someone with dementia is physically and emotionally demanding. Feelings of anger and guilt,frustration and discouragement, worry, grief, and social isolation are common.If you're a caregiver for someone with dementia:Learn as much about the disease as you can and participate in caregiver education programmes.Find out about supportive services in your community, such as respite care or adult care, which can give you a breakfrom care-giving at scheduled times during the week.Ask friends or other family members for help.Take care of your physical, emotional and spiritual health.Ask questions of doctors, social workers and others involved in the care of your loved one.Join a support group.

FRAILTY SYNDROMEWHAT IS:Frailty is a common geriatric syndrome. The occurrence of frailty increases incrementally with advancing age, and ismore common in older women than men, and among those of lower socio-economic status. Frail older adults are at highrisk for major adverse health outcomes, including disability, falls, institutionalization, hospitalization, and mortality.SCREENING TESTS FOR FRAILTY: The frailty syndrome requires at least three of the following five characteristics:• unintentional weight loss, as evidenced by a loss of at least 10 lbs or greater than 5% of body weight in the prior year;• muscle weakness, as measured by reduced grip strength in the lowest 20% at baseline, adjusted for gender and BMI;• physical slowness, based on measured time to walk a distance of 15 ft;• poor endurance, as indicated by self-reported exhaustion; and• low physical activity, as scored using a standardized assessment questionnaire.

TREATMENT:Nutritional Considerations for FrailtyNutrition is an important component to consider in the evaluation of frailty.Many factors contribute to poor nutritional status in the elderly. Weight loss often occurs secondary to an underlyingcondition that may be either physical or psychological and can affect a patient’s ability to consume adequate calories orprotein on a daily basis to maintain optimal functional status.

Treating FrailtyUnrecognized drug side effects as well as drug-drug interactions can cause unexpected adverse effects that canpredispose patients to weakness, slowness (both physical and mental), and falls. Frequent medication review canidentify opportunities for medication reduction and avoid polypharmacy.A comprehensive exercise programme and increased physical activity have been shown to benefit the frailty syndrome.Muscle weakness and muscle disuse atrophy resulting from a sedentary disposition and chronic illness respond well tophysical therapy.

NON-COMUNICABLE - OR CHRONIC - DISEASESWHAT IS:A non-communicable disease (NCD) is a medical condition or disease that is not caused by infectious agents (non-infectious or non-transmissible) such as:

- autoimmune diseases, - heart diseases, - stroke, - cancers, - diabetes, - chronic kidney disease, - osteoporosis, - Alzheimer's disease, - cataracts, and others.

RISK FACTORSRisk factors such as a person's background; lifestyle and environment are known to increase the likelihood of certainnon-communicable diseases. They include age, gender, genetics, exposure to air pollution, and behaviors suchas smoking, unhealthy diet and physical inactivity which can lead to hypertension and obesity, in turn leading toincreased risk of many NCDs. The WHO's World Health Report 2002 identified five important risk factors for non-communicable disease, these are:

- raised blood pressure, - raised cholesterol, - tobacco use, - alcohol consumption,- overweight and - social determinants of health.

CARDIOVASCULAR DISEASEWHAT IS:Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. Cardiovascular diseaseincludes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include:

- stroke, - heart failure, - hypertensive heart disease, - rheumatic heart disease, - cardiomyopathy, - heart arrhythmia, - congenital heart disease, - valvular heart disease, - carditis, - aortic aneurysms, - peripheral artery disease, - thromboembolic disease and - venous thrombosis.

RISK FACTORSThere are many risk factors for heart diseases: age, gender, tobacco use, physical inactivity, excessive alcohol consumption, unhealthy diet, obesity, geneticpredisposition and family history of cardiovascular disease, raised blood pressure (hypertension), raised blood sugar(diabetes mellitus), raised blood cholesterol (hyperlipidemia), psychosocial factors, poverty and low educational status,and air pollution. SCREENING TESTS FOR CARDIOVASCULAR DISEASE:

Screening ECGs Some biomarkers may add to conventional cardiovascular risk factors in predicting the risk of future cardiovasculardisease. Future preventative screening appears to shift toward applying prevention according to randomized trial resultsof each intervention rather than large-scale risk assessment.PREVENTIONUp to 90% of cardiovascular disease may be preventable if established risk factors are avoided. Currently practicedmeasures to prevent cardiovascular disease include:Tobacco cessation and avoidance of second-hand smoke. A low-fat, low-sugar, high-fiber diet including whole grains and fruit and vegetables. At least 150 minutes (2 hours and 30 minutes) of moderate exercise per week. Limit alcohol consumption to the recommended daily limit. Lower blood pressure, if elevated. A 10 mmHg reduction in blood pressure reduces risk by about 20%.Decrease non-HDL cholesterol. Decrease body fat if overweight or obese. Decrease psychosocial stress.CHRONIC OBSTRUCTIVE PULMONARY DISEASEWHAT IS:Chronic obstructive pulmonary disease (COPD) is a type of disease characterized by long-term breathing problems andpoor airflow. The main symptoms include shortness of breath and cough with sputum production.RISK FACTORS:smoking (the primary risk factor for COPD globally is tobacco smoking), air pollution (poorly ventilated cooking fires,often fueled by coal or biomass fuel ssuch as wood and dung, lead to indoor air pollution and are one of the mostcommon causes of COPD), occupational exposures (intense and prolonged exposure to workplace dusts, chemicals andfumes increase the risk of COPD), genetics (genetics play a role in the development of COPD), other.DIAGNOSIS AND SCREENING TESTS FOR COPD:

spirometry severityThe modified British Medical Research Council questionnaire (mMRC) or the COPD assessment test (CAT) are simplequestionnaires that may be used to determine the severity of symptoms.

PREVENTION:Most cases of COPD are potentially preventable through decreasing exposure to smoke and improving air quality.Annual influenza vaccinations in those with COPD reduce exacerbations, hospitalizations and death. Pneumococcalvaccination may also be beneficial. The non-typable Haemophilus influenzae vaccine (NTHi) when taken by mouth doesnot appear to reduce exacerbations in people with COPD. Prevention include:

- smoking cessation,- occupational health,- air pollution.

DIABETES MELLITUS TYPE 2WHAT IS:Diabetes mellitus type 2 (also known as type 2 diabetes) is a long-term metabolic disorder that is characterized by highblood sugar, insulin resistance, and relative lack of insulin.RISK FACTORS:The development of diabetes is caused by a combination of lifestyle and genetic factors:lifestyle (lifestyle factors are important to the development of diabetes, including obesity and being overweight : definedby a body mass index higher than 25, lack of physical activity, poor diet, stress, and urbanization), genetics and medicalconditions (there are a number of medications and other health problems that can predispose to diabetes)DIAGNOSIS AND SCREENING TESTS FOR DIABETES MELLITUS:The World Health Organization’s definition of diabetes (both type 1 and type 2) is for a single raised glucose reading with

symptoms, otherwise raised values on two occasions, of either:fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl) or with a glucose tolerance test, two hours after the oral dose a plasmaglucose ≥ 11.1 mmol/l (200 mg/dl)

PREVENTION:Onset of type 2 diabetes can be delayed or prevented through proper nutrition and regular exercise.MUSCULOSKELETAL DISORDERSWHAT IS:Musculoskeletal disorders are among the most common problems affecting the elderly. The resulting loss of mobilityand physical independence can be particularly devastating in this population. With age, musculoskeletal tissues show increased bone fragility, loss of cartilage resilience, reduced ligament elasticity,loss of muscular strength, and fat redistribution decreasing the ability of the tissues to carry out their normal functions.RISK FACTORS:MSDs can arise from the interaction of physical factors with:

- ergonomic,- psychological, - social and - occupational factors.

PREVENTION:There are evidence-based interventions that can be used to educate the public on the prevention of these disorders.Examples are as follows:Osteoporosis prevention programmes.Fall prevention programmes.Public education programmes resulting in reduced resource utilization.Programmes addressing back pain or increased physical activity.]

Safe lifting programmes for health care workers.Workplace ergonomics programmes for both primary and secondary prevention.

LONELINESS AND SOCIABILITY IN OLD AGEWHAT IS:Loneliness might be described as negative feelings or sadness brought on by a lack of communication, companionship orrelationships with other people. Loneliness can affect anyone of any age, but older people are particularly vulnerable tofeeling lonely. Loneliness is not the same as being alone, and has nothing to do with how many people your relativesees. It's the quality of social contact that makes all the difference. It's possible to be in a relationship, or live with family,and still feel lonely. Your relative might be surrounded by carers but still feel lonely if they are missing friends, family or apartner, or if they can't be as active as they used to.MAIN CAUSES OF LONELINESS:Retirement: people might miss day-to-day contact with work colleagues, plus the routine of getting ready and going outto work.Bereavement: chronic loneliness can unfortunately set in after the loss of a partner. Similar feelings of loneliness canarise if one relative moves to a care home and the other is left alone at home. Lack of friends and companions: friendsmay have passed away, no longer live in the same area or have restricted mobility that stops them from getting out andabout.Poor physical health: ill health or loss of mobility can make it more difficult to socialise.Location: your relative may not live near family and friends, particularly if they are living in a residential carehome where choices of location might be limited. Modern life means that families are often more ‘geographicallyscattered’ – living further apart due to jobs or family break ups.Lack of transport: your relative may no longer be able to drive for health reasons, or no longer own a car. If they live in arural area public transport might be limited. Financial problems can also limit travel. Not being able to leave the house asoften as they'd like reduces opportunities for social contact and can lead to feelings of social isolation.Financial difficulties: in addition to causing stress, financial problems can also limit travel. Not being able to leave thehouse as often as they'd like reduces opportunities for social contact and can lead to feelings of social isolation.PREVENTION:

Most people who are lonely want to increase the quality or quantity of their contact with other people. There are manyways you can help your relative overcome loneliness, and you can find suggestions here on this page, including:- strengthening family ties,- changing living arrangements- spending time outside of the home,- finding transport solutions,- getting online,- making new friends,- befriending services,- helping others and- animal companions.

SUPPORT AND SERVICES FOR CARING FOR OLDER PEOPLE AT HOME

Most of us want to live at home for as long as we can. This is often possible with a little extra help and support. Thisdoesn’t necessarily mean they need to move in to an aged care home or you need to start doing all these things forthem. There are lots of support services that can help.Support for the essentials:The basic level of home-care assistance involves ensuring homes are safe and clean and that gardens are tidy and freefrom hazards. Meals on Wheels delivers economical meals to people who can’t cook for themselves. For those who findit doesn’t meet their needs, care workers can also come to their homes to prepare meals.Community transport is available for taking the elderly to medical appointments. It also often runs shopping trips andother excursions. Trained home-care workers are able to help with bathing and personal care. They can also help ensuremedications are being taken and in the prescribed doses, while also keeping an eye on the clients. “Care workers aretrained to notice changes in the clients’ condition and report back to family.If a loved one has dementia you don’t necessarily need to move them in to aged care straight away. With some carefulmanagement and the right help, people living with dementia can live safely at home for longer.PRESENTATION OF HEALTHCARE SOCIAL NETWORK SHAREHOLDERS IN EVERY COUNTRY IN WHICH THE EDUCATION ISIMPLEMENTED

12. The Social Business Model

The ‘Social’ Business Plan model has been created within the framework of theCo.N.S.E.N.So. project [founded by the Alpine Space Programme - ID-ASP286] by a team ofexpert of PP10 ‘ECECE’ with the purpose of defining an easy-to-use tool for the same future‘social’ entrepreneurs whobecome immediately the mainexperts and analysts of theirown businesses.

As a matter of fact, the modelcomes to life by differenttraining / consultancyexperiences to businesscreation implemented by theauthors themselves, having asmain objective thedissemination of knowledge,and therefore awareness, foraspiring entrepreneurs with

respect to the basic issues of doing business and operational management of their economicactivities.

At the same time, however, this tool is fulfilling one of the basic functions of the BusinessPlan, which is the structured and analytical presentation of the business idea to third partiesto which the nascent team caters for financial, economic and / or commercial purposes (witha specific insight into the social dimension of the referred business sector).

This model is thus centred on the exploration of the ‘social dimension’ of the business itself,starting from the mapping and engagement of the relevant stakeholders and then clearlystating, structuring and measuring the real social targets and impacts of the company’saction.4

In details, the model consists of 3 separate tools which all contribute to the drafting of thefinal analytical document, namely:

o a descriptive model (in Word format) for the qualitative explanation of theentrepreneurial action,

o an analytical model (in Excel format) for the processing of the economic / financialinvestigation using all the information collected in the descriptive part, 5

o guides / studies / papers (in PDF) to facilitate the understanding and therefore theuse of the proposed tools.

The same choice of commonly used tools is dependent upon the desire to provide a simplemodel truly addressed to the same aspiring entrepreneurs, in order to facilitate theevaluation of convenience and effectiveness of their business idea and thus support its"surfing" during the difficult first three years of activity.

12.1. Training objectives and contents

“Social entrepreneurship is about finding some stakeholders and creating value for them.And it doesn't matter whether it's for profit or not for profit. In this sense, a stakeholderentrepreneur is somebody who starts or improves an organization by making it responsiveto a stakeholder's needs or a set of stakeholder's needs”. 6

4 Purpose of this part of the analysis is to clearly state and measure (even in economical terms) thesocial impact of the company’s services and then defining the proper strategy for the ‘negotiation’ with thepublic & private operators.5 All the charts & tables have been reported on the descriptive model to have a unique and completetool for the Business analysis

6 R. Edward Freeman for the MOOC course “New Models of Business in Society” by University of Virginia

The project Co.N.S.E.N.So. is intended to provide the target Family and Community Nurses 7

with the basic knowledge to acquire and then master basic contents on social businessplanning and management, addressing their operation to existing business players in thesocial sector or to cooperate with them.

In this sense first the FCNs should receive a basic training on Social Business planning andmanagement, tailored to regional peculiarities and needs, and then should be beneficiariesof tailored support to better test on the field the proposed Social Business Model to guidefuture social enterprise start-ups in the field.

Training contents & structure synopsis

T h e b asic co n ten ts & to o ls a re p ro vid ed b y P P 10 in E n g lish lan g u ag e …

… an d are ‘cu sto m ised ’ & tran s lated b y P P exp erts . . .

… an d d el ivered to lo cal F C N s b y P P exp erts.

1

5 th e m a t ic a re a s

2 3 4 5

L o c a l / re g io n a l t ra in in g

L eg a l a s p ec t s in B u s in e s s p la n n in g

& m a n ag e m en t

T h e M a rk e t in g d im e n s io n

O rg a n is a t io n & M G M T

B u d g e t & a cc o u n t ab ilit y

T h e B u s in e s s o f S o c ia l

Loc a l / r e g ion a l w o rk s hops to tr a ns fe r b a s ic k now le dge on B us ine s s p la nn ing & m a na g e m e nt

Minimum standard = 5 W S o f 4 hou rs e a c h covering basic knowledge

12.2. Training structure

All in total the training structure consists of 6 seminars of 4 hours each to be displayed atthe project FCNs within February 2018, having in details the following structure. 8

7 Co.N.S.E.N.So. project aims at developing a care model that is built on the pivotal role of the Familyand Community Nurse (FCN), playing an innovative role, becoming the key actor who shapes and managespersonalised services for the elderly and their families, particularly those living in isolated areas. Each partnerRegion tests the FCN-based model of care in a selected area where all elderly (≥ 65 years), healthy or not, areassigned to a single FCN. Each FCN follows up to 500 hundred elderlies with periodical home visits.8 All the contents listed here are neither exhaustive nor formally applicable in full in each regionalcontest: on the contrary they must be adapted and customised according to regional / national peculiarities.

N° Title Duration Date

Seminar 1 The idea, organisation and management 4 hours dd/mm/2017

CONTENTS:

Introduction to the business plan as a tool for the analysis of the business idea

Definition of the NATURE of the business and description of the PRODUCTS &SERVICES

Setting the PURPOSE and the TARGET GROUP

Defining the PRODUCTION PROCESS and the role of SUPPLIERS and PARTNERS

The company’ STAFF: need, roles and functions

The idea of COMPETITIVE ADVANTAGE

TARGET: the FCNs should acquire a basic knowledge on the need and function of aBusiness Plan as well as a first insight on the main assets of the structure of the business idea

--- --- ---

N° Title Duration Date

Seminar 2 The market and marketing dimension 4 hours dd/mm/2017

CONTENTS:

The MARKET (a): features, dimensions and trend

The MARKET (b): characteristics and size of potential targets

MARKET PENETRATION STRATEGY: the social dimension in the forefront

PRICING and gross MARGIN TARGETS: basic principles

COMMUNICATION & SALES STRATEGY: basic principles and tools

TARGET: the FCNs should acquire a basic knowledge on the market, its dimension andpotentialities as well as the main tools and strategies to better enter the target market andexploit the company’s potentialities

--- --- ---

N° Title Duration Date

Seminar 3 Legal aspects in business start-up & management 4 hours dd/mm/2017

Anyway both the overall structure [i.e. 24 hours of training + the 5 main field of intervention] and the basictarget per seminar should be respected.

CONTENTS:

Legal Forms of business start-ups: types and main differences

Company statute, roles and responsibilities of members (basic)

Formal procedures and formalities for start-up

Agreements and contracts: manage business relationships

Main fiscal duties in the country / region

TARGET: the FCNs should acquire a very basic insight on the main legal aspects andprocedures dealing with the start-up and the management of internal (i.e. the Statute) andexternal relationships

--- --- ---

N° Title Duration Date

Seminar 4 Budgeting & accountability 4 hours dd/mm/2017

CONTENTS:

Defining and implementing the COST STRUCTURE

Defining and setting the REVENUE STREAMS

The BREAK EVEN POINT

Introduction to the PROFIT & LOSS ACCOUNT

The concept and function of the CASH-FLOW

Sources of FINANCIAL COVERAGE

Understanding and measuring the economic performance end the businesssustainability and profitability

TARGET: the FCNs should acquire a very basic insight on the concepts of revenues,company’s costs, investments, economic & financial objectives, profit as well as the basicelements of the economic benefit analysis (starting from the structure and charts reported inthe Social Business Model)

--- --- ---

N° Title Duration Date

Seminar 5 The business of social 1: testing the model 4 hours dd/mm/2017

CONTENTS:

Detecting STAKEHOLDERS: PURPOSE of the engagement, PROFILING & IDENTIFYINGstake-holders, ENGAGING stakeholders

The main TARGET group: beneficiaries v/s customers

The business of SOCIAL: customers v/s patients, setting and economic value of theservice and identifying donors (profiling)

The SOCIAL DIMENSION of the business: social outcomes and social impacts

TARGET: the last two seminars are intended to test and eventually validate theCo.N.S.E.N.So. Social Business Model profiting of the experience of the FCNs also acquiredduring the piloting phase.9 This first part will be mainly centred in sharing & collecting thefirst inputs on the real ‘social dimension’ of the business itself, starting from the mappingand engagement of the relevant stakeholders and then clearly stating, structuring andmeasuring the real social targets and impacts of the company’s action.

--- --- ---

N° Title Duration Date

Seminar 6 The business of social 2: validating the model 4 hours dd/mm/2017

CONTENTS:

MAPPING limit and constraints of the FCNs’ action

INPUTS to the Model: the Family & Community Nurses Social Enterprise (simulating areal start-up collecting inputs & data) 10

LAUNCHING the Model: detecting and eventually stimulating a possible start-updriven by the Co.N.S.E.N.So. FCNs

VALIDATING the Model: summing up all the inputs

TARGET: this second part should provide a sort of validation of the proposed Modelgiving evidence of the limits and constraints under which it could be really applied in theregion. After a desk validation by processing all the inputs collected during the previousseminar (and the previous research) this final workgroup should result in a sort of‘simulation’ of a real start-up by the FCNs using the Model

12.3. Feedbacks from the field

With the sole exception of the French partners, where the training that has taken place wasnot perfectly centred on the proposed Social Business Model,11 all the other regions followed

9 The Model testing and validation will be the result of, firstly, a desk research implemented by theregional experts and then a joint collaboration with the FCNs providing their practical experience also acquiredduring the pilot phase. The main purpose of this activity is to detect whether and under which conditions thisSocial Business Model could be applied in each involved region.10 Inputs and data collected on the field from the FCNs should be validated by desk researchesaccording to regional / national experiences.11 Due to the status and actual business model of nurses in France, where if the National regulation willnot change there’s not a concrete opportunity for private action in this field, it became obvious that it wouldnot be useful to carry out such a training to the French pilot nurses. Therefore the training with the Var nurses

this training framework and contents with simple customisations as required by regional /national regulations, norms and peculiarities, as well as logistical elements.

In general, all the contents and the main analyses have been clearly ‘acquired’ by the nurseswith, in particular, evidence of the following main feedbacks:

all participants found the contents interesting and relevant for their activity, despite thefact that is not in their field of expertise (anyway the Model itself resulted as a valid andeasy-to-understand reference for studying the social business),

as usual more technical contents (i.e. legal aspects and economic & financial provisions)have been more critical and less practised,

as for the Marketing dimension more practical and day-by-day operations (e.g. word-of-mouth) have proved to be more effective rather than the theoretical approaches,

Management skills and competencies needed to manage the business have raised someworries and probably confusion.

All these findings have been then processed to implement and release the updated & finalversion of Output 4.2 - The Social Business Model.

13. Training report and evaluation

Training report is prepared on the basis of the training programme performed in Izolabetween 27 June and 1 July 2016, participants lists, and written (pencil-paper questionnaire)evaluation of the training programme. The evaluation of the training was performed on thelast day of the training (1st July 2016). The report includes three chapters: (i) trainingperformance, (ii) training participants, (iii) training evaluation.

a.) Training performance

The training held in Izola between 27 June and 1 July was not specifically planned in theproject documentation. Nevertheless, during the coordination with project partners,especially the partner PP2, the idea of unitary training week was developed and decided (onthe meeting on 2 March 2016, held in UP FVZ), since otherwise the unitary idea of theproject (transnational, transcultural) would not be achieved. Country specific training wouldnot guarantee the idea of holistic alpine-space approach. The 5-days training programmeheld in Izola was a starting training programme for nurses that will work on Consenso modelimplementation and/ or country specific training providers. The training program consisted

have been centred on the following contents:- Training on digital approaches to care and coordination for the FCN in particular through the platform

Facilien;- State of the art of public policy and the CoNSENSo business model- State of the art of nurses training in France and needs of FCN- Brainstorming on required competences- Benchmarking of existing diplomas in M1 and M2- Conception of a diploma structure with modules, ECTS credits, budget

of 45 hours (60 minutes) of presentations, lectures and workshops. In Table 1 speeches,lectures and workshops included in the training programme are presented.

b.) Training participants

The target population of the training programme held in Izola were nurses that willparticipate in the implementation of the CONSENSO model of care and country specifictraining providers. The training participants were also project partner’s representatives,since they have the role as lecturers – training providers. All project partners Regionsparticipated at the training – Slovenia, Italy, France and Austria. Table 2 presents the numberof participants from each day of the training programme.

Table 2: Number of training participants for each day of the training programme

Monday - June 27

Tuesday – June 28

Wednesday – June 29

Thursday – June 30

Friday- July 1

57 50 58 56 55

c.) Training evaluation

For the purpose of the training programme evaluation UP FVZ has developed Participants’satisfaction evaluation questionnaire, presented in Appendix 1 of this report. Thesatisfaction evaluation questionnaire included three parts:- Satisfaction evaluation of different satisfaction criteria: (i) contents intelligibility, (ii) contents usefulness for the implementation of the model in the frame of the project, (iii) contents diversity (was enough diversity of contents provided to keep your attention during the training programme?), (iv) training programme organization (facilities, schedule, lecturesand workshops duration), (v) training programme location, (vi) overall level of satisfaction with the training programme. Participants evaluated their satisfaction with each of the satisfaction criteria on 5-point evaluation scale, ranging from 1 (very dissatisfied) to 5 (very satisfied). - Open-ended questions upon: (i) additional comments, suggestions, or problems concerning the training programme in Izola; (ii) contents that should be deepened within national level education in the frame of the CONSENSO project.- Demographic information: (i) type of participation (three possible responses: a) nurse, who will carry out the project activities; b) a project partner representative, c) other), (ii) years of experience in the field of health care.In the evaluation process 40 training participants rated their satisfaction with the trainingprogramme. In table 2 the results of the evaluation of each satisfaction criteria is presented for thetraining participants that completed the questionnaires (N = 40). From marks given to eachof the satisfaction criteria we calculated descriptive statistics: N of responses, minimummark, maximum mark given to each of the criteria, average, standard deviation and median.

Table 2: Results of the satisfaction with training evaluation – evaluation criteria

Evaluation criteria N ofresponses

Min Max Average Standarddeviation

Median

CONTENTS INTELLIGIBILITY 40 2 5 3,98 0,80 4CONTENTS USEFULNESS FOR THE IMPLEMENTATION OF THE MODEL IN THE FRAME OF THE PROJECT

40 1 5 3,20 0,97 3

CONTENTS DIVERSITY (was enough diversity of contents provided to keep your attention during the training programme?)

40 2 5 3,60 0,78 4

TRAINING PROGRAMME ORGANIZATION (facilities, schedule, lectures and workshops duration)

39 2 5 3,64 0,96 4

TRAINING PROGRAMME LOCATION 40 2 5 4,33 0,83 5

OVERALL LEVEL OF SATISFACTION WITH THE TRAINING PROGRAMME

40 2 5 3,73 0,75 4

Table 3 shows that participants were the most satisfied with the »training programmelocation« (M = 4,33, SD = 0,83) and »contents intelligibility« (M = 3,98; SD = 0,80).Participants were the least satisfied with the criteria »contents usefulness for theimplementation of the model in the frame of the project« (M = 3,20; SD = 0,97).Nevertheless, also this criteria was evaluated by participants with an average mark higherthan 3,00. Overall satisfaction with the training program was evaluated with an averagemark 3,73 that shows a positive (satisfactory) attitude towards the performed training.

Besides quantitative measures of satisfaction, we utilised also a qualitative approach to thesatisfaction analysis. We asked the participants two open-ended questions: (i) remarks andcomments about the training and (ii) contents that should be deepened within national leveleducation in the frame of the CONSENSO project. Participants’ comments were transcribedand group in accordance to the repetition of certain themes presented in the participants’comments and opinions. Table 4 presents most frequent comments on the trainingperformed in Izola.

Table 4: Most frequent comments on the training performed in Izola.

Comments Nmb. ofcomment

sMore workshops and discussions 7Translations – influence on timetables and understanding, lack of simultaneous interpreter 7Taking more into account the time schedule of the training 4Would like to have more comparisons of different realities related to the nursing care in different countries 2More concrete information and work on CONSENSO project 2More concrete information on how to do in practice the community nursing, assessment, visits, questionnaires

1

More clear distinction between decisions that have to be taken on the strategic level (project partner) and a group of nurses

1

The process of team building should be placed in the beginning of the training 1

It should be useful at the very beginning of the training to let the participants share their background model, expectations, desires, in order to build the team

1

Needed brochure for the training 1

The most frequent comment from participants was about the need to perform the trainingin more interactive manner – in workshops and in discussions that would allow for theexchange of the experience between nurses. The second most frequent comment was onsimultaneous translation. Participants of the training were not familiar enough with Englishlanguage, therefore UP FVZ organised the training programme in a way that all languages ofparticipants (English, Italian, German, Slovene) were taken into account. Translation wasperformed by training participants and project partners in Italian, German, and frequentlyalso in English language. Such translations sometimes extended the completion of lectureswhich influenced also the time schedule. Participants also commented on the need to getfamiliar with country-differences in the field of community and family nursing and to getmore knowledge on how they will concretely work in the field during the phases ofCONSENSO Model of care implementation.

Table 5 presents the gathered answers on the open-ended question on which contentsshould be depended within national level education programs.

Table 5: Contents to be deepened within national level education

Comments Nmb. of commentsQuestionnaires to use 2Frailty 1Specific competences related to the CONSENSO nurses role 1The role and specific competences of the community and family nurse 1Health prevention 1Administration – utilisation of the APP on the PC 1

The most frequently proposed content to be applied on the level of country specificeducational program was the questionnaires to be utilised during the home visit of theCo.N.S.E.N.So. community family nurse (diagnostic/ screening tools, evaluation criteria andmeasures). Other contents were also: the concept of frailty, competences of theCo.N.S.E.N.So. community family nurse and competences of the community and family nursein general, health prevention and administrational task of Co.N.S.E.N.So. community andfamily nurses during the implementation of the Co.N.S.E.N.So. Model of care (training in PCand APP utilisation). The core content to be applied on the country-specific level ofeducation is the implementation of the Co.N.S.E.N.So. Care mode and specific roles that thenurses have in this process. The evaluation of the training shows that the training was on average successful andsatisfactory for participants. Nevertheless, the evaluation shows also the need for carefullyplanning of the country (national) level education for nurses that will work on theimplementation of Co.N.S.E.N.So. Model of care, especially in the part of concrete nursingprocesses and activities to be implemented during the elderly home health visit. UP FVZ(PP7) would like to pay attention that the provided training programme was prepared with

the cooperation of project partners (especially PP2, PP3, PP4, PP8, PP9). Three differentversion of training programme were prepared between March and June 2016. Eachproposed training programme was presented to the project partners and corrected inaccordance to their feedback. The first training programme for the training week in Izola waspresented in Acceglio between 13 – 14 April 2016 by UP FVZ team members. The last andthe implemented training program was revised during the meeting held in Izola on 22 June2016 with project partners (PP1, PP2, PP7, PP8, PP9).

14. Training activities performed by each country partner individually

Training activities performed by each country partner individually.

Italy

In Italy the training activities started on the 15th of September 2016 and completion is planned onthe 15th of September 2017, in total 1500 of training hours will be performed, of these 480 hoursrepresent lectures to Co.N.S.E.N.So. nurses and 1020 hours consist of Co.N.S.E.N.So nurses’independent study hours. The training is carried by the University of Turin. The number of expectedECTS is 60. At the end a PHD In Family and community Nursing is achieved.

The competences that the graduate nurses will obtain in Italy in order to carry out the Co.N.S.E.N.Socare model are:

- Therapeutic Relationship;- Counselling;- Case Management ( assessment, planning, facilitation, care coordination, evaluation,

advocacy);- Health Promotion;- Empowerment Of Citizens;- Integrated Care;- Inter-Professional Relationship;- Older People Disease Management;- Early detection and management of frailty in older people.

The evaluation of the participants’ knowledge during and after the completion of training will beperformed with exams.

The basic idea (purpose and objectives) of the training programme was based on the fact that theepidemiological and demographic changes require generalist-specialist professionals who are able toidentify and assess the health status and the needs of individuals and families in their culturalcontext and in the community. Furthermore the Co.N.S.E.N.So nurses should be able to promotehealth and to support the empowerment of citizens, identify and propose appropriate e-healthsolutions, propose innovative and sustainable health and social care solutions and plan and provideassistance to families with special needs activating the network of services and fostering theintegration of care. Italian partners see the potential of this training programme to be further

developed as a transnational master or specialization study programme in the field of nursing andother health and social care professions.

The four key (basic) contents for nurses carrying out the Co.N.S.E.N.So care model, which are alsostressed as key contents for a successful execution of the project, are:

- Therapeutic relationship;- Counselling;- Health Promotion;- Case Management.

The following contents were intended to be performed as e-learning courses:

- The Nursing in the context of Primary Care and Public Health;- Nursing research;- Prevention and management of chronic diseases;- E-health.

The participants who will be involved in the model implementation in Piemonte region are:

- Lingua Arianna (Nurse);- Ribero Martina (Nurse);- Sansone Francesca (Nurse);- Chiapello Elisa (senior).

The participants who will be involved in the model implementation in Liguria region are:

- Fretto Antonella (senior);- Poli Francesco (Nurse);- Salvadori Lorenzo;- Nigro Francesca;

Austria

In Austria the training activities started on the 4th of May 2016 and completion is planned on the30th of September 2017, in total 928 of training hours will be performed, of these 403 hoursrepresent lectures to Co.N.S.E.N.So nurses and 525 hours consist of Co.N.S.E.N.So nurses’independent study hours. The number of expected ECTS is 90.

The competences that the graduate nurses will obtain in Austria in order to carry out theCo.N.S.E.N.So care model are:

- Advanced Health Promotion And Prevention;- Public Health;- Case Management;- Family Centered Nursing;- Sociology;- Science And Critical Thinking;- Assessment And Screening Tools;- Communication, Education, Coaching;

- Psychology And Crisis Intervention;- E-Health And Telemedicine;- Law (Concerning Health And Social);- Advanced Nursing Practice (Chronic Diseases, Pharmacy, and Examination).

The evaluation of the participants’ knowledge during and after the completion of training will beperformed at the University of Applied Sciences Upper Austria.

The basic idea (purpose and objectives) of the training programme was based on the four presentedcore modules of the University of Turin concerning the advanced nursing education in Family andCommunity Nursing:

1. FCN role in the primary care settings. Research for health and social care;2. Communication skills in delivering care and promoting health; use of e-health and remote tools;3. Proactive nursing and case management of long term conditions;4. Case studies and ongoing training in family and community settings.The four key (basic) contents for nurses carrying out the Co.N.S.E.N.So care model are:

- Family Centred Nursing;- Assessment Tools;- Public Health Focused On Families;- Health Promotion and Prevention.

The four key contents for a successful execution of the project are:

- Structure Of Health System;- E-Health;- Caregiver Burden And Coping Strategies;- Law (social and health).

The following contents were intended to be performed as e-learning courses:

- Education, Coaching, Training Of Care Givers;- Know-How Transfer Theory-Praxis;- (Nursing) Diagnostic Process.

The participants who will be involved in the model implementation in Austria are:

- Ingrid Breithuber (FCN);- Sandra Dobrounig (FCN);- Claudia Gregorn (FCN);- Judith Wistrela (FCN);- Susanne Kofler (FCN);- Eva Sachs-Ortner (FCN);- Ingrid Pichler-Wagner (FCN).

France

In France the training activities started on the 12th of September 2016 and completion is planned onthe 9th of March 2018, in total 342 of training hours will be performed, of these 270 hours represent

lectures to Co.N.S.E.N.So. nurses and 72 hours consist of Co.N.S.E.N.So. nurses’ independent studyhours. The training is not intended to be carried out as a formal study programme.

The basic idea (purpose and objectives) of the training programme in France is based on theachievement of the three (basic) competencies for nurses carrying out the Co.N.S.E.N.So. care modelin their country:

- Coordinating a territorial project;- Evaluate the situation of the senior at home;- Developing an educational posture.

To develop these competencies, the action training was entrusted to the Regional Centre ofVocational Training (C.R.F.P.) of the French Red Cross. The aforementioned training additionallyincludes:

- Project Coaching;- Analysis of Professional Practices.

French partners see the potential of this training programme to be further developed as atransnational master or specialization study programme in the field of nursing and other health andsocial care professions as well as LLL-programmes.

The competences that the graduate nurses will obtain in Italy in order to carry out the Co.N.S.E.N.So.care model are:

- Understanding public health in different dimensions;- Use public health methods and tool;- Develop a Health Education approach;- Develop a posture adapted to the mission;- Develop a suitable communication;- Know how to take care of chronic pathological situations at home;- Reporting knowledge on major chronic diseases;- Know how to take care of chronic pathological situations at home;- Exchange on practices.

The evaluation of the participants will be implemented as follows. A survey will be used before thestart of the formation by the formation provider. The first day of training an assessment ofknowledge and about the awareness of the project have been done. A similar survey will be done atthe end of the formation.

The following contents were intended to be performed as e-learning courses. The content is stillunder preparation and it will be designed as two units:

- Project Coaching;- Analysis of Professional Practices.

The following participants will be involved in the model implementation in France:

- Lucie RICHE (Student);- Catherine Perot BOIRIN (Student);- Marie-Christine Rigaud (Teacher).

Slovenia

In Slovenia the training activities started on the 15th of September 2016 and completion is plannedon the 15th of December 2017, in total 1500 of training hours will be performed, of these 210 hoursrepresent lectures and 680 hours clinical work to Co.N.S.E.N.So nurses and 610 hours consist ofCo.N.S.E.N.So nurses’ independent study hours and e-learning method. The number of expectedECTS is 60.

The competencies that the graduate nurses will obtain in this training in order to carry out theCONSENSO care model are prepared on the background ICN competencies model for communitynurses:

o Coordinating a territorial project;

o Research: Identifying practice problems and seeking answers and solutions throughscientific investigation alone or in collaboration, Early detection and management offrailty in older people;

o Identifying the needs and nursing problems of the elderly people, their families andthe communities in which they live, early detection and management of frailty inolder people, Evaluate the situation of the senior at home

o Health promotion and education for elderly people and their families (formal andinformal) about health care and illnesses, acting as the main provider of healthinformation;

o Care provider and supervisor: providing direct care and supervision of care providedby others, including family members, nursing assistants and other professionalsaccording to the needs of the elderly people;

o Elderly and family advocacy: Working to support elderly people and families andtalking about the issues such as safety and access to services;

o Case finder and epidemiologist: Tracking disease and playing a key role in diseasesurveillance and control;

o Management and coordination: Managing, collaborating and liaising with familymembers, health and social services and others to improve access to care;

o Counselling: Playing a therapeutic role in helping to cope with problems and toidentify resources, creation the therapeutic relationship;

o Consulting: Serving as consultant to elderly people, their families and agencies toidentify and facilitate access to resources;

o Environmental modification: working to modify, for example, the home environmentso that the disabled can improve mobility and engage in self-care.

The evaluation of the participants’ knowledge during and after the completion of training will beperformed with oral exams and preparation of scientific paper. Several interviews will be performedbefore, during and after the training.

Similarly as in Italy the basic idea the of the training programme is based on the fact that thedemographic and epidemiological changes require a specific nursing profile – a generalist-specialist

professional who is able to identify and assess the health status and the needs of elderly and familiesin their cultural context and in the community; to be able to promote health and to support theempowerment of citizens, identify and propose appropriate e-health solutions, propose innovativeand sustainable health and social care solutions. This will help to provide assistance to elderly peoplefamilies activating the network of services and fostering the integration of care. Slovenian partnerssee the potential of this training programme to be further developed as a transnational master study,specialization for nurse, as well as life-long learning study programme for nurse and otherstakeholders involved in the care of the elderly.

The four key (basic) contents for nurses carrying out the Co.N.S.E.N.So. care model, according to theSlovenian partners, are

o Research: Identifying practice problems and seeking answers and solutions throughscientific investigation alone or in collaboration, Early detection and management offrailty in older people;

o Health promotion and education for elderly people and their families (formal andinformal) about health care and illnesses, acting as the main provider of healthinformation;

o Care provider and supervisor: providing direct care and supervision of care providedby others, including family members, nursing assistants and other professionalsaccording to the needs of the elderly people;

o Counselling: Playing a therapeutic role in helping to cope with problems and toidentify resources, creation the therapeutic relationship.

Almost all of the aforementioned contents were intended to be at least partially included in the e-learning system. Content aimed at specific knowledge in the field of healthy living habits, control ofchronic non-communicable diseases, palliative care and use Nanda NIC and NOC nursing diagnoses. Itis also important that in the form of e-learning we will offer the possible health social network ofstakeholders that will take care for elderly and their family in the specific country.

The participants who will be involved in the model implementation in Slovenia are:

• Jolanda Lamot,• Katja Štajner,• Tjaša Hrovat,• Neli Kovšča,• Nataša Kocijan,• Cvetka Lorger,• Ingrid Glažar,• Alenka Sukič,• Julka Križman.

Conclusions

The trainings in all partners’ countries started between the 4th May 2016 and the 15th September2016. The trainings are expected to be finished until 9th March 2018. The total number of traininghours varies from 342 to 1500. Such variation can be explained due to the fact that Italian partnersare planning to implement this training as a part of MSc course; hence, the planned number oftraining hours is tailored also for the implementation of this course in academic settings.

In all the partner countries, the common fields of competencies listed by the partners are:

- health promotion;- public health;- health education;- communication.

Italian and Austrian partners noted also the importance e-health competencies. Slovenian partnersstressed also the importance of information security. Austrian partners will include in their trainingthe acquisition of competencies required to understand the health and social legislation. Despitesome differences in planned (and performed) trainings, the Co.N.S.E.N.So nurses will, according tothe presented trainings, acquire the required knowledge and gain the competencies required for thesuccessful implementation of the model in practice.

The satisfaction of Co.N.S.E.N.So. nurses with the implementation of curricula

With the last questionnaire sent to CoNSENSo nurse via e-mail, we wanted to find out thesatisfaction of nurses with the implemented programs in each country. The table below summarizesthe results for all four countries.

AnsverAverage Standard

deviation

Core modules contents 3.7 0.8

Contents relevance for the implementation of the consenso project 3.4 0.9

Contents diversity (was enough diversity of contents provided to keepyour attention during the training programme?) 3.6 0.8

Training programme organization (facilities, schedule, lectures andworkshops duration) 3.4 0.7

Length of the programme 3.3 0.9

E-learning contents and facilities 3.2 0.9

Overall level of satisfaction with the training programme 3.5 0.8

Given the average evaluation of the answers to all the questions, we can say that nurses weresatisfied with the education in individual countries.

15.References

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familes and populations. Elsevier Saunders.Nursing and midwifery council. 2010. Standards for competence for registered nurses. Nursing and midwifery council. 2010. Standards for pre-registration nursing education.Obbia, P. 2014. Introducing the family health nurse in Italy. Int J Integr Care. Ozmec, T., Mohorko, T.B., & Lipič, N. (2014). Sodobni pristopi k izboljšanju informiranosti in

medgeneracijskega sodelovanja v Sloveniji. V D. Železnik, U. Železnik, & S. Gmajner(ur.), 4. znanstvena konferenca z mednarodno udeležbo s področja zdravstveni ved:Pomen kompetentne obravnave uporabnikov zdravstveni in socialnih storitev v časukrize, Laško 9. september 2014 (str. 129-139). Slovenj Gradec: Visoka šola zazdravstvene vede.

Ramovš, J. (2015). Deinstitucionalizacija dolgotrajne oskrbe. Kakovostna starost, 18(3), 3-25.Ramovš, K. (2015). Razbremenitev družinskih oskrbovalcev z vidika ZDA in nekaterih

evropskih držav. Kakovostna starost 18(2), 22-33.Valenčak, S. (2012). Kaj je starosti prijazno in kaj ne? Kakovostna starost, 15(1), 3-19. World health organization (WHO). 1999. HEALTH21: The health for all policy framework for

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World Health Organization. 2006. Fifth Workshop on the WHO Family Health NurseMultinational Study. Copenhagen: WHO Regional Office for Europe.

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16.Appendix

Appendix 1: Five-day training to the extent of 45 hours, carried out inSlovenia for all Co.N.S.E.N.So nurses involved in the project implementation

Content LecturersProject Co.N.S.E.N.So: purpose,objectives and activities Project Partners'Presentations (Management andOrganization of Community and FamilyNursing in the participating countries)

Giuseppe Salamina, Tamara ŠtembergerKolnik , Dalibor Müller (A), MarieChristine Rigaud (FR)

Community and family nurse supportingElderly Model and implementation of theModel

Tamara Štemberger Kolnik, Ester Benko

Community and family nurse supportingElderly – nurse’s competences

Ginetto Menarello, Pasquale Giuliano

Workshop on community and familynurse supporting Elderly - Home visit (1stPart): Nurses assessment, plan,

Ester Benko, Suzana Zugan, KatarinaMerše Lovrinčević

intervention and reassessment:presentation of a case study anddiscussion in small groupsWorkshop on community and familynurse supporting Elderly - Home visit (2ndPart): Nurses assessment, plan,intervention and reassessment:presentation of a case study anddiscussion in small groups

Ester Benko, Suzana Zugan, KatarinaMerše Lovrinčević

Integrating health and social care toimprove quality of life of the elderly Mirko Prosen

Non-profit health and social organisationsin Slovenia :

Helena Videtič, Nataša Kocjan, HelenaHostnikar, Anja Kovač

Workshop on community and familynurse supporting Elderly - Home visit (3rdPart): Nurses assessment, plan,intervention and reassessment:presentation of a case study anddiscussion in small groups

Ester Benko, Suzana Zugan, KatarinaMerše Lovrinčević

Ergonomics of elderly living environment David RavnikSpiritual care of the dying and theirfamilies

Doroteja Rebec, Katarina Babnik

Frailty: concept definition, itsinterrelation with individual and socialdeterminants of health

Paola Obbia, Ernesto Palummeri

Appendix 2: Training Programme Certificate of Attendance

This is to certify thatname and surname

has participated as a lecturer (or participant, member of organization staff) in a five-day training entitled:

Five-day training programme for Community and family nurses for elderly

organised by University of Primorska, Faculty of Health Sciences, from June 27th to July 1th 2016

Earning our gratitude for making significant contribution towards: challenge oriented interdisciplinary and multi-cultural group-work lectures and workshops of international experts

“Project Co.N.S.E.N.So: purpose, objectives and activities”“Community and family nurse supporting Elderly Model”“Community and family nurse supporting Elderly – nurse’s competences”“Workshops on community and family nurse supporting Elderly Model - Home visit: Nurses assessment, plan,

intervention and reassessment: presentation of a case study and discussion in small groups”“Integrating health and social care to improve quality of life of the elderly”“Ergonomics of elderly living environment”“Spiritual care of the dying and their families”“Frailty: concept definition its interrelation with individual and social determinants of health”“Evaluation of the model implementation and the concept of Quality of life”

“Training for e-learning and APP utilisation (tablet and applications)”

In order to develop competences in the field of: Community and family nursing Elderly nursing care Utilisation of e-learning platform of CO.N.S.E.N.SO project and CO.N.S.E.N.SO project App.

Annexed training programmePartner 1. Leader Regione Piemonte, Direzione Sanità, Assessorato Sanità2. Azienda Sanitaria Locale Torino 13. Regione Liguria4. Accademia Nazionale di Medicina5. Département du Var6. Association pour le Développement des Entreprises et des Compétences7. Univerza na Primorskem Fakulteta za zdravstvene vede8. Inštitut RS za socialno varstvo9. Amt der Kärntner Landesregierung10. European Center of Entrepreneurship Competence & Excellence

Giuseppe Salamina Tamara Štemberger KolnikTechnical Coordinator UP Faculty of Health Sciences

Appendix 3: Annex to the Certificate of Attendance

Annex to the certificate of attendance in a five-day training programme for Co.N.S.E.N.SoCommunity and family nurses for elderly, organised by University of Primorska, Faculty of

Health Sciences, from 27 June to 1 July 2016

UP Faculty of Health Sciences is a partner in the project Co.N.S.E.N.So, responsible for theTraining programme (WT1) for nurses working on the implementation of Co.N.S.E.N.Sofamily and community nursing care model. UP Faculty of Health Sciences organised a five-day training programme for Co.N.S.E.N.So Community and family nurses for elderly from 27June to 1 July 2016. The training programme consisted of 45 hours (60 minutes) ofpresentations, lectures and workshops. was held Taking into account the direct contacthours of lectures, group workshops and participants’ independent work we estimate thatthe performed training programme for Co.N.S.E.N.So Community and family nurses forelderly could be evaluated with 6 European Credit Transfer and Accumulation System (ECTS)points.

This annex is valid jointly with the Certificate of attendance in a five-day training programmefor Co.N.S.E.N.So Community and family nurses for elderly.

Tamara Štemberger Kolnik, M.Sc. Assoc. Prof. dr. Nejc Šarabon, DeanCoordinator of the UP Faculty of Health SciencesCo.N.S.E.N.So. project atUP Faculty of Health Sciences

Appendix 4: Training programme in Italy

Programme of the Post Graduate Diploma in Family and Community Nursing

“on demand” for the Alpine Space Project CO.N.S.E.N.SO60 ects

This new innovative educational programme focuses on working with older adults in ruralareas and on the critical thinking skills required to fostering ageing at home. The programmeacknowledges the health challenges of an increasingly ageing population, the need of earlydetection of frailty in older adults and the long term diseases management complexity. Itbuilds on the past experience of the Turin University that since 2005 delivers PGD in Familyand Community Nursing, as well as on European Family and Community Health experiencesand international literature.

The PGD aims to provide participants the following core competencies:

Activation of health promotion interventions and strategies oriented to self-helpmanagement and empowerment of citizens to influence and participate in decisionsconcerning their health;

Role of “helper and counsellor”: the nurse helps the individual, the family and thecommunity to assess their health needs and promotes the access to the availableresources

Role of case manager: assessing needs, planning care, advocating for the patient andacting as a link between individual, family, community, and health and socialsystems;

Facilitation of safe and effective transitions across levels of care and care sites,including acute, community-based, and long-term care for individuals and families;

Activation of informal resources in the community networks (neighborhood, parentalgroups and associations in the community, parish, etc.) and promotion of socialinclusion interventions;

Orientation for the access and use of services offered by the local health and socialservices;

University of Turin Department of Clinical and Biological Sciences

and Department of Psychology

“Master in Infermieristica di Famiglia e di Comunità”Post Graduate Diploma in Family and Community Nursing

Facilitation the integration of services and professionals across levels of care and caresites;

Early detection and management of frailty condition in older adults; Planning, coordinate and manage care, including that delegated to other people and

personnel ( home care assistants, family members, etc.) and evaluation of theoutcomes;

Clinical monitoring and management of long-term diseases through innovativestrategies, including e-health;

Working in team with other professionals and enhancing trans-professionalcollaboration.

The programme 5 Modules are delivered part in class and part on-line through the VirtualLearning Environment “Moodle”.

Health 2020: the new European health policy framework to supportaction across government and society to improve the health andwell-being of populations

MOODLEStrategy and action plan for healthy aging in Europe 2012- 2020 -WHO – Regional Office for EuropeWHO Global report on non-communicable diseasesWHO Global action plan for prevention and control of non-communicable diseases 2013-2020

International and national public health policies CLASS

The family and community nurse role in the primary care context CLASS

The social determinants of health and their impact on people living inrural areas CLASS

MODULE 1: THE NURSING PRACTICE IN THE PUBLIC HEALTH AND INTHE PRIMARY CARE CONTEXT E-learning 25 hours Class 42 hours

LEARNING OUTCOMES Understand the historical development of Primary Care.Understand local laws and rules related to primary care organisation and management.Critically analyse the role of the Family and Community Nursing in different primary carecontexts.Analyse the major determinants of health and critically evaluate global, national and localpolicies improving public health.Understand the demographic, environmental, cultural and socio-economic factorsinfluencing the health of people living in mountain areas.

Literature search: definition, aims and methods

MOODLE

Bibliographic databasesScientific journalsCritical reading of a scientific articleAnalysis of guidelinesSystematic reviews and meta-analysisHistorical notes on the development of the epidemiologyDefinition of epidemiologyThe cause and effect relationshipAccuracy and precision of an epidemiological studyFrequency measurementsThe statistical significance

LEARNING OUTCOMES Understand research studies and epidemiological study designsAcquire skills in literature search and evaluate research findings related to evidence basedpracticeCritically appraise health and social care scientific literatureCollect, manage and use clinical, research-based and statistical information (data) forplanning care and prioritizing health- and illness-related activitiesPlan and take part in qualitative studies Understand and use the methods of collecting qualitative data: individual interview, in depthinterview, narrative interview, focus groups.

The counseling to individuals and families CLASS

MODULE 2: RESEARCH E-learning 75 hours

MODULE 3: CONCEPTS AND PRINCIPLES OF HEALTH PROMOTION ANDHEALTH COMMUNICATION Class 86 hours

Principles and methods of health promotion, health education andtherapeutic patient education (TPE)

CLASS

The construction of a therapeutic education project CLASSThe psychological, organisational, social and community empowerment CLASSMethods and tools for empowerment and outcomes evaluation Methods and tools for improving therapeutic adherence and resilience CLASSSelf-help Group CLASSHome visiting first interview: tools and methods CLASSMotivational interview CLASSTelephone interview and phone call follow-up CLASS

LEARNING OUTCOMES

Apply the basic principles of individual and family counselingAssess the educational needs of those assistedUnderstand the principles and methods of health promotion, health education andtherapeutic patient education (TPE)Design and implement interventions of therapeutic patient education (TPE) with individuals,caregivers and family members Improve the adherence to treatments through informative / educational interventions andregular supervisionApply strategies to enhance people's resilience and empowermentUse of motivational interviewing to strengthen the people’s motivation to change andengagement in health behavioursApply engagement strategies and activate actions of support in the community network offormal and informal care

The nursing assessment: evaluation methods and scales CLASSThe systemic reading of the communications in the family network: thegenogram

CLASS

The narrative collection of people's health story CLASSThe case management CLASS

LEARNING OUTCOMES

Implement a nursing multidimensional assessmentCollect people’s health story trough the narrative approach Make a systemic reading of the older adults family relationshipsApply the principles and methods of case management for the care of older adults

MODULE 4: TAKING CARE OF COMMUNITY DWELLING OLDERADULTS Class 42 hours

Early detection, prevention and management of the frail condition in olderpeople

CLASS

Multi morbidity and polypharmacy CLASSThe environment and the chronic diseases CLASSThe clinical pathways and guide lines: their use in the clinical practice CLASSHealth promotion for physical activity and healthy nutrition CLASSSmoking and excessive alcohol consumption CLASSHome safety CLASSThe person affected by dementia MOODLE

The person with heart failure MOODLE

The person with respiratory diseases MOODLE

The person with diabetic disease MOODLEE-health for older people and the evidence based guidelines for Nursingand Social Care on eHealth Services: the ens4care guidelines MOODLE

LEARNING OUTCOMES

Understand the concept of frailty in older people and the importance of the early detectionand evaluate the feasibility of proactive and preventive interventions

Evaluate risky behaviour Analyse the living environment and identify possible risks Assess the home safety and evaluate possible interventionsAcquire in depth knowledge of long term diseases and their clinical managementUnderstand the principles, tools and ethics of e-health for older peopleTotal programme hours 1500E-learning 228Class 222Placement 500Thesis 50Individual study 500

MODULE 5: PREVENTION AND MANAGEMENT OF FRAILTY AND LONGTERM DISEASES Class 52 hours E- learning 118

hours

Appendix 5: Training programme in Austria

1. Semester

Block 1 Wochentag Datum Uhrzeit UE ∑ UE ECTS ∑ ECTS

Mittwoch 4.5.2016 Welcoming address

Mittwoch 4.5.2016 Health- and social policy Role of Advanced Nurse Practitioners in society and organisations

4 4 0,5 0,5

Mittwoch 4.5.2016 Health- and social policy Models and concepts of advanced nursing practice

4 8 0,5 1

Mittwoch 4.5.2016 Science Working with scientific reviews 2 10 0,5 1,5

Feiertag

Freitag 6.5.2016

Samstag 7.5.2016 Assessment und Diagnostic Handling documentation and documentation systems

8 18 3 4,5

Block 2 Izola 27.06.2016 -

01.07.2016 Outcome measurement Data and data quality 8 26 1 5,5

Izola 27.06.2016 -01.07.2016

Outcome measurement Outcome measurement of quantitative and qualitive analysis

8 34 2 7,5

Praktikum Selecting, initiating and implementing of knowledge into practice

3 10,5

Block 3 Wochentag Datum Uhrzeit UE ∑ UE ECTS ∑ ECTS

Montag 4.7.2016 Introduction Demographic and epidemiological trends and their impact on family care systems

8 42 1 11,5

Dienstag 5.7.2016 Science Deepening into methods: data collection and analysis

10 52 1 12,5

Mittwoch 6.7.2016 Health- and social policy Multicultural images of human beings 8 60 0,5 13

Donnerstag 7.7.2016 Introduction Basic principles of the systems theory 8 68 1 14

Freitag 8.7.2016 Health- and social policy International care-concepts 8 76 1 15

Block 4 Dienstag 20.9.2016 Intervention Surveying questions from former experience,

developing solutions, realising it to practice4 84 2 17

Mittwoch 21.9.2016 Assessment und Diagnostic Handling documentation and documentation systems

8 92 2 19

Donnerstag 22.9.2016 Assessment und Diagnostic Diagnostic process 8 100 1 20

Freitag 23.9.2016 Health- and social policy Structure of health and social welfare systems 8 108 0,5 20,5

Blended Learning G:

Counselling Education of patients and relatives (informing, training, counselling)

1 21,5

Blended Learning G:

Counselling Counselling, coaching of informal carers und stakeholders

2 23,5

∑ UE ∑ ECTS

108 23,5

2. SemesterBlock 5 Wochentag Datum Uhrzeit UE ∑ UE ECTS ∑ ECTS

Mittwoch 12.10.2016 Assessment and Diagnostic E-Health 8 8 2 2

Donnerstag 13.10.2016 Outcome measurement Cross-linking of data inside and outside the organisation

8 16 1 3

Freitag 14.10.2016 Empowerment Empower patients 8 24 1 4

Samstag 15.10.2016 Introduction Familial sociology 8 32 1 5

Praktikum Research application Selecting, initiating and implementing of 2 7

knowledge into practiceBlock 6 Montag 21.11.2016 Science Statistics in order to understand research

results4 36 0,5 7,5

Dienstag 22.11.2016 Science Statistics in order to understand research results

8 44 1 8,5

Mittwoch 23.11.2016 Counselling Education of patients and relatives (informing, training, counselling)

8 52 2 10,5

Donnerstag 24.11.2016 Counselling Counselling, coaching of informal carers und stakeholders

8 60 2 12,5

Freitag 25.11.2016 Science Evaluation research 8 68 1 13,5

Block 7 Wochentag Datum Uhrzeit UE ∑ UE ECTS ∑ ECTS

Montag 12.12.2016 Specialization Models and concepts of caring for families 8 76 1 14,5

Dienstag 13.12.2016 Science Deepening into methods: data collection and analysis

2 78 0,5 15

Dienstag 13.12.2016 Research application Development of practice concepts 8 86 1 16

Mittwoch 14.12.2016 Science Critical thinking 8 94 1 17

Mittwoch 14.12.2016 Science Working with scientific reviews 2 96 0,5 17,5

Donnerstag 15.12.2016 Health- and social policy Health promotion, prevention, public health 8 104 1 18,5

Freitag 16.12.2016 Specialization Culture-specific phenomena in families 8 112 1 19,5

Blended Learning G:

Assessment and Diagnostic Diagnostic process 2 21,5

Blended Learning G:

Intervention Clinical practice - theory - practice-transfer under the aspect of a process-oriented criteria

2 23,5

Einzel-termine

Counselling Individual coaching 3 115 1 24,5

∑ UE ∑ ECTS

115 24,5

3. SemesterBlock 8 Wochentag Datum Uhrzeit UE ∑ UE ECTS ∑ ECTS

Montag 23.1.2017 Outcome measurement Development of key figures 4 4 1 1

Dienstag 24.1.2017 Intervention Use of clinical expertise under the aspect of effectiveness and efficiency criteria

8 12 2 3

Mittwoch 25.1.2017 Introduction Public health, focusing families 8 20 1 4

Donnerstag 26.1.2017 Empowerment Empower patients 8 28 1 5

Block 9 Dienstag 21.2.2017 Intervention Feelings and identity work 8 36 1 6

Mittwoch 22.2.2017 Professionell development in nursing Priorization on behalf of the aims of an organisation

4 40 2 6

Mittwoch 22.2.2017 Introduction Role, partners, settings in caring for families 6 46 0,5 8,5

Donnerstag 23.2.2017 Introduction Role, partners, settings in caring for families 2 48 0,5 8

Donnerstag 23.2.2017 Specialization Needs and requirements of children, youth, adults and erlder people in a family unit

8 56 2 11

Freitag 24.2.2017 Specialization Needs and requirements of children, youth, adults and erlder people in a family unit

8 64 2 13

Block 10 Wochentag Datum Uhrzeit UE ∑ UE ECTS ∑ ECTS

Montag 20.3.2017 Empowerment Prof. Empowerment: Networking, Lobbying, Product marketing of ANP, Policy making, Media work

8 72 0,5 13,5

Dienstag 21.3.2017 Empowerment Prof. Empowerment: Networking, Lobbying, Product marketing of ANP, Policy making, Media work

8 80 0,5 14

Mittwoch 22.3.2017 Specialization Methods of family centered care 8 88 2 16

Donnerstag 23.3.2017 Specialization Methods of family centered care 8 96 2 18

Praktikum Research application Selecting, initiating and implementing of knowledge into praxis

4 22

∑ UE ∑ ECTS

96 22

4. SemesterBlock 11 Wochentag Datum Uhrzeit UE ∑ UE ECTS ∑ ECTS

Montag 24.4.2017 Research application Development of practice concepts 8 8 1 1

Dienstag 25.4.2017 Health- and social policy New developments in health and social law 8 16 1 2

Mittwoch 26.4.2017 Specialization Case- and caremanagement 4 20 1 3

Mittwoch 26.4.2017 Specialization Interface management 4 24 1 4

Donnerstag 27.4.2017 Specialization Special forms of communication in caring for families

8 32 2 6

Praktikum Research application Selecting, initiating and implementing of knowledge into praxis

4 10

Block 12 Montag 29.5.2017 Professionell development in nursing Needs assessment, identification of feasible

occupations4 36 2 12

Montag 29.5.2017 Professionell development in nursing Nursing reporting 4 40 1 13

Dienstag 30.5.2017 Specialization Poverty of famlies 8 48 1 14

Block 13

Wochentag Datum Uhrzeit UE ∑ UE ECTS ∑ ECTS

Montag 3.7.2017 Specialization Prevention in families 8 56 1 15

Dienstag 4.7.2017 Specialization Prevention in families 4 60 1 16

Dienstag 4.7.2017 Health- and social policy New developments in health systems 4 64 1 17

Mittwoch 5.7.2017 Specialization Decision making process in a family unit 4 68 1 18

Mittwoch 5.7.2017 Specialization Caregiver burden and coping strategies 6 74 0,5 18,5

Donnerstag 6.7.2017 Specialization Caregiver burden and coping strategies 2 76 0,5 19

Donnerstag 6.7.2017 Specialization Education and training of family members, informal carers concerning performing care

8 84 1 20

∑ UE ∑ ECTS

84 20

Appendix 6: Training programme in France

TRAINING A TEAM OF STATE CERTIFIED NURSESIN ONE OR MORE TERRITORIES OF THE VAR

ACCORDING TO THE TEACHING METHODS OF THE"FAMILY AND COMMUNITY NURSES” MODEL

JULY 2016 CURRICULUMDraft

IRFSS of PACA & CorsicaOllioules Site201 Chemin de Faveyrolles - CS 0000383192 Ollioules Cedex

Tel.: 04 94 93 66 00e-mail: irfsspacac@croix-rouge.fr

CONTENTSpage

1 SKILLS OF THE CO.N.S.E.N.SO NURSES AND THE TRAINING COURSE4

2 AREAS OF EXPERTISE AND SUPPORT SYSTEM

6

3 TRAINING COURSE ORGANIZATION17

As part of the CO.N.S.E.N.SO project, the Regional Professional Training Center (C.R.F.P.) ofthe Red Cross Regional Health and Social Training Institute (I.R.F.S.S.) took part in a 5 daytraining course in Slovenia organized by the University of Primorska in Izola, in June 2016.Following this participation, and as stipulated in the special technical clauses, Direction VarEurope should be provided with a training curriculum (Part 1b).

This document presents: The skills of the CO.N.S.E.N.SO nurses and the training course The various areas of expertise and the support system The training course organization

SKILLS OF THE CO.N.S.E.N.SO NURSES AND THE TRAINING COURSEThe training action is aimed at developing the 3 areas of expertise of

CO.N.S.E.N.SO nurses in their territorial medical-social coordination mission

Coordinating a territorial project Evaluating the situation of seniors living at home Developing an educational postureIn order to achieve this goal, a support system has served the CO.N.S.E.N.SO over the past 18months. It is composed of:

Project coaching Analysis of Professional Practices

The table below compares the organization of the "Family and community nurse" master'sprogram with the University of Turin and our curriculum for the C.R.F.P..Var. CO.N.S.E.N.SOProject.FAMILY and COMMUNITY NURSE MASTER'SDEGREE

curriculum ProjectCO.N.S.E.N.SO CRFP Var

TITLE VOLUME455 hours

TITLE VOLUME342 hours

IN-CLASS 88 % IN-CLASS 78 %MOD 1 Public Health Coordinating a territorial

project96

MOD 2 Health education Developing aneducational posture

108

MOD 3 Communication Evaluating the situationof seniors living at home

66

MOD 4 Care MOD 5 Chronic diseaseMOD 6 WorkshopDISTANCE LEARNING DISTANCE LEARNINGCOURSE 1 Changes in primary

care in an internationalcontext

Areas of expertise 1, 2,and 3

Included ineach module

COURSE 2 Research methodologyCOURSE 3 Advanced clinical study SUPPORT ADV + work in

representativesituations

12 % ADV + Project coaching 21 %

In our training course, the focus is placed on the role of coordination in connection withnational and territorial medical/social policies. Project support is emphasized, since 21 % of the training is dedicated to it.

AREAS OF EXPERTISE:

AREA OF EXPERTISE 1: COORDINATING A TERRITORIAL PROJECT

Objectives: Learning about public health in various dimensions. Specifying the modalities for caring for persons over 65 years old in the Var and the

project experimentation territory. Developing a posture adapted to the coordination mission.

Content elements: Presentation of the Co.N.S.E.N.So. project. Determinants of health according to the W.H.O. International and national public health policy. Local information networks and the role of the community nurse in primary care. Demographic, cultural, economic and social factors, and their impacts on health in

the various territories. W.H.O. reports: World Health Report 2008: Primary Health Care (Now More Than

Ever), 2008 W.H.O. report Gaining health. Analysis of policy development in European countries for tackling

noncommunicable diseases, World Health Report 2008 Social determinants of health and public health programs, 2010 W.H.O. report

Building primary care in a changing Europe, 2015 W.H.O. report2016 Health Act.

Act No. 2015-1776 of December 28, 2015 regarding society's adaptation to ageing. Departmental Plan 83 for Autonomy 2014-2018. 2015 study report from the Department of the Var Quality Mission – "Study on the

elderly receiving the personalized autonomy allocation and on a social intervention inthe Department of the Var."

Studies and evaluations conducted by the Department's Autonomy Section on thesubject of maintaining the elderly at home.

List of home support arrangements funded by the Department of the Var. Arrangements funded by the Autonomy Section, home support budgets and funding. 2013-2015 commitment plan for the Department of the Var. CLIC, MAIA. PAERPA and presentation of PAERPA Eastern Var. Collaboration, cooperation, partnership, coordination: definitions and characteristics.

Coordination: role and missions within the CO.N.S.E.N.SO project. Position regarding Project partners and local players.

Duration:78 hours, i.e.,13 days60 hours in initial training, i.e.,13 days18 hours in ongoing training, i.e., 3 days

Teaching methods:17/NOV/2016 = Participation in the "Cooperation in Health and Social services" conferenceorganized by I.R.F.S.S. at the IAE Nice siteIn-class Distance learning: E LEARNING / CO.N.S.E.N.SO tabletMapping the territories of Grimaud, Gassin, La Garde Freinet, La Môle, Le Plan de la Tour,and Le Rayol CanadelTerritory: Social development, issues, limitations, strengths, and weaknesses Local health and medical/social structures, existing networks, home-support associations,independent professionals, etc.

Population of the territory: age pyramid, morbidity and mortality rates, accident rates,hospitalization rates, average income, etc.

This representation of local characteristics was begun in September by the CO.N.S.E.N.SOnurses and is added to as the project progresses.

Participants:Stéphan Jakob: medical/social policies in the VarJocelyne LAFFON: coordination

Participants from the General Council: Direction Var Europe Noel Felten special adviser, CO.N.S.E.N.SO project Autonomy Section Sophie Sarano or a representative Territorial Social Department: Philippe Loubet Del Par or a representativeGerontology Support and Coordination Service: Géraldine Gerfaud or a representativeDepartmental Home for Disabled Persons: Jean Paul Faure or a representativeAutonomy Evaluation and Benefit Service: Frédéric Gastou or a representativeDepartment 83 Regional Health Agency Dr. Anne de CoppetC.C.A.S. GrimaudAnne Charlotte SalviC.O.D.E.S. 83 Pierre Coupat Deputy Director

AREA OF EXPERTISE 2 DEVELOPING AN EDUCATIONAL POSTURE

Objectives:

Health education Developing the expertise of teaching caregivers Dispensing a program of Therapeutic Patient Education (E.T.P.) Building an educational approach within the framework of multi-disciplinary care Implementing a therapeutic learning program Leading individual and collective learning sessions Coordinating a program of Therapeutic Patient Education (E.T.P.) Uniting a team around the E.T.P. approach Evaluating in order to help evolve Communicating in order to optimize Empowerment and Counseling Developing communications and a suitable relationship with the elderly at home and

with territorial partners

Content elements: Concepts of: health, prevention, promotion, health education, disease education and

therapeutic education Knowledge of regulatory frameworks

Accounting for the affective condition, life, experience, and representation of peoplein educational care

Recognition of the person's needs Empathetic communication and communication techniques Concepts in therapeutic education Representations of chronic disease The concept of skills The educational program: project methodology Identifying the steps of an educational approach Educational diagnostic and objectives in the respect for the personal project Selection and use of relevant educational techniques and tools Evaluation of the therapeutic effects of education Building a therapeutic educational approach within the framework of multi-

disciplinary care E.T.P. implementation The role of the professional in therapeutic education The position of the care-giving educator The educational diagnosis or shared educational assessment Observance Educational methods and techniques Facilitation techniques The role of facilitator within groups Family counseling Psychological, organizational, social, and community empowerment Instruments and methods for evaluating empowerment after a

prevention/promotion intervention Therapeutic adherence and resilience: methods and tools for development Identifying the skills of team members suited to the needs of the program, and to

individual needs Developing the conditions favorable to motivating teams (material conditions, team

training, human resource management, organization in institutional environments,etc.)

Capitalizing on the team's experience and the expertise of other teams, in order toimprove the program's operation

Discussing the involvement of a patient participator Analyzing the context of the project in therapeutic education Building a Therapeutic learning approach Working with the team to design a relevant assessment system for running the

program Coordinating the annual assessment and drafting a quadrennial assessment report Promoting the program based on the assessment Raising awareness of research in the E.T.P. Identifying communication issues Selecting the significant information and lessons learned over the course of the

program Knowing the ad hoc communications channels and vectors

Developing a communication plan Developing arguments (oral and written) to arouse the interest of the public,

partners, and institutions

Duration: 108 hours, i.e.,18 days: 6 hours: health education 42 regulatory hours: dispensing therapeutic training to the patient (curriculum under

May 31, 2013 Order) 42 regulatory hours: coordinating a therapeutic training with the patient 18 hours: empowerment, counseling….

Teaching methods: In-class interventions Distance learning: E LEARNING / CO.N.S.E.N.SO tablet Participants: Christine Dutheil: E.T.P. Patricia Cohen Solal: E.T.P. Martine BALAYN: counseling, empowerment

AREA OF EXPERTISE 3 EVALUATING THE SITUATION OF SENIORS LIVING AT HOME

Objectives:

Learning the frailty indicators for the elderly. Updating knowledge on the principles of chronic diseases. Updating knowledge on home-care in the context of chronic pathologies. Knowing the ergonomic design options and aids to help with everyday actions. Knowing how to train the elderly at home in appropriate movements and postures. Developing appropriate communications with the elderly and their friends and family

at home Developing appropriate communications with the territorial partners of the

CO.N.S.E.N.SO project

Content elements: Concepts of frailty: assessment and anticipation Prevention and early diagnosis of frailty of the elderly through the use of specific

measurement scales Loss of autonomy Good treatment and prevention of mistreatment Pharmacology and the elderly Epidemiology of chronic diseases over different territories Impact of lifestyle on the onset of chronic diseases and their complications

Support for caregivers If advanced clinical knowledge is needed: Physiopathology Chronic bronchitis and asthma Cardiovascular decompensation Cardiac arrhythmia Stroke Arterial hypertension Diabetes Cognitive disorders in old age Senile dementia Alzheimer's disease and related diseases

Ergonomic household modifications Aids for everyday living Movements and postures "Fall prevention" course, balance workshop Conducting interviews Phone interviews and follow-up interviews Motivational interview Life stories, data collection Group dynamics Role, functions, and tasks Different types of meetings Leading a cross-disciplinary team Cross-disciplinary communication

Duration:66 hours, i.e.,10 days

Teaching methods: In-class interventions Distance learning: E LEARNING / CO.N.S.E.N.SO tablet Possible use of: Guide for autonomy (Department of Bas Rhin) Serious game: University of Toulon12 (pétanque game, cooking game)

Participants: Sophie ABULKER: cognitive disorders Nicolas BROCANDEL: ergonomics Mikael DEBONO: communication Dr. Robert MARZIALE: fragility

SUPPORT SYSTEM

12 "Serious games for active aging." A Abellard, P. Aellard laboratoire 13 M, University of Toulon, La Garde , in Annéegérontologique Communications orales et affichées, Thursday March 17, 2016, 2016 page 65

PROJECT COACHING

Objective:Supporting nurses through the 18 months of the CO.N.S.E.N.SO project

Duration: 46 hours, 2 hour coaching sessions

Methods: In-class Presentation of the project and the roles of the various participants Presentation with D.V.E. of the CO.N.S.E.N.SO tablet and the L.M.S. Initial assessment quiz with evaluation of level of English fluency (CO.N.S.E.N.SO

tablet) Assessments at mid-term (June 2017) and at the end of the project (March 2018) of

the nurses' knowledge and skills Collection of personal plans, expectations, and needs of nurses at the start and over

the 18 months of experimentation Evaluation of nurses' satisfaction at the end of training (French Red Cross satisfaction

survey + oral assessment) Distance learning

Coaches: Marie Christine RIGAUD Agnès PARIS

ANALYSES OF PROFESSIONAL PRACTICESObjectives:

Analyzing the professional situations encountered as part of the CO.N.S.E.N.SO, bothin meeting the elderly and their friends and loved ones, as well as meeting withterritorial players.

Developing a reflexive posture enabling the connection between knowledge andprofessional situations

Duration: 26 hours total, i.e., 13 x 2 hour A.P.P. sessions

Methods: Distance learning

Participant:Sophie ABULKER

3 TRAINING COURSE ORGANIZATION

DURATION OF AREAS OF EXPERTISE AND OF THE SUPPORT SYSTEM

AREAS OF EXPERTISE TITLE DURATION TOTAL

1 Coordinating a territorial project 96 hours 270hours2 Developing an educational posture 108 hours

3 Evaluating the situation of seniors living athome

66 hours

SUPPORT SYSTEM TITLE DURATION TOTALProject coaching 42 hours 72 hoursAnalysis of Professional Practices 26 hours

342CO.N.S.E.N.SO PROJECT: A.E. and SUPPORT

PROGRESSION

Initial training, weeks 37 and 40 Ongoing training after that until March 2018 The initial training begins with Area of Expertise 1 "coordinating a territorial project." Indeed, it is essential for Co.N.S.E.N.So nurses to be enlightened on the national and

departmental medical/social policy measures in order to best handle thecoordination function.

This first step promotes understanding of and adherence to the Co.N.S.E.N.So bylocal health and medical/social players.

This is why Co.N.S.E.N.So nurses are asked to establish a precise map of the localplayers connected to the target population in the 5 towns involved. The many studiesand interventions of AE 1 promote this thorough inventory work.

Next, the ongoing training develops the 2 other Areas of Expertise: "Developing an educational posture" "Evaluating the situation of seniors living at home" Through this theoretical background, the nurses should better understand their

encounters with seniors from the territory and coordinate at-home interventions in apersonalized manner.

The "frailty of the elderly" study and appropriating health education approaches areproposed. In fact, "the condition of frailty is a reversible condition and thisreversibility implies, among other things, the involvement of the subject. Therapeuticeducation...appears to be an essential support in the area of fragility. " 13

Educational skills are increased through training "dispensing therapeutic training tothe patient" (curriculum under May 31, 2013 Order). It is supplemented by anotherarrangement: "coordinating a therapeutic learning program."

Following these 2 programs, the nurses receive a training certificate for each of them.

ADAPTABILITY

13 Therapeutic education and frailty: a way to remain autonomous? Zueras, A.Perrin, S.Sourdet, C. Dupuy, M. Pedra, H.Villars, F. Nouhashemi, B. Vellas, Gérontopôle Toulouse, in Année gérontologique Communications orales et affichées, Thursday March 17,2016, 2016 page 65

This training project action serves the Co.N.S.E.N.So project. Thus, based on its developments in the territories concerned and based on the needs of thenurses, it can be adjusted.

PROVISIONAL TIMETABLE

The training is organized with 2 weeks of initial training in September and October 2016, andcontinues until March 2018 through ongoing training.This ongoing training features complementary methods: in-class and distance learning (E-learning using the Co.N.S.E.N.So app for tablets, coaching, and APP).

It includes: Participation in the conference organized by the Red Cross Training Institute and

I.A.E. Nice, "Cooperation in Health and Social services," November 17, 2016, Participation in the Direction Var Europe days starting in June 2017, Initial, mid-term, and final assessments.

Taking into account vacation periods, the table below proposes the provisional 2016/2018timetable

NUMBER OFHOURS

IN-CLASS DISTANCE LEARNING TOTAL

IT OT COACHING APP E

LEARNING

SEPTEMBERDECEMBER2016

60 30 14 4 10 118

JANUARY JUNE 2017

60 16 10 12 98

JULYDECEMBER2017

60 10 6 4 80

JANUARYMARCH 2018

30 6 6 4 46

TOTAL60 180 46 26 30 342

No. DAYS IN-CLASS 10 30

Co.N.S.E.N.So PROJECT: PROVISIONAL TIMETABLE 2016 / 2018

The following table proposes a week-by-week view of the training from September 2016to March 2018.

Co.N.S.E.N.So PROJET PROVISIONAL TIMETABLE BY WEEK

TITLE METHODS DURATION

sept-16week37 FI IN-CLASS 30

PRESENTATION OF THE Co.N.S.E.N.SoPROJECT INITIAL ASSESSMENT EXPECTATIONS

week38 OT DIST 4

week39 OT DIST 4

oct-16week40 FI IN-CLASS 30

week41 OT DIST 4

week42 OT IN-CLASS 6

week43 OT DIST 4

nov-16week44 OT IN-CLASS 6

week45 OT DIST 4

week46 OT IN-CLASS 6

Participation in "Cooperation inHealth and Social services"conference, IRFSS site Nice + IAE Nice9 am - 4:30 pm

week47 OT DIST 4

week48 OT IN-CLASS 6

dec-16week49 OT DIST 4

week50 OT IN-CLASS 6

jan-17week1 OT DIST 2

week2 OT IN-CLASS 6

week3 OT DIST 4

week4 OT IN-CLASS 6

week5 OT DIST 4

feb-17week6 OT IN-CLASS 6 week7 OT DIST ? 2 SCHOOL VACATIONweek8 OT DIST ? SCHOOL VACATION

week9 OT IN-CLASS 6

march-17week10 OT DIST 4

week11 OT DIST 4

week12 OT IN-CLASS 6

week13 OT DIST 4

apr-17week14 OT IN-CLASS 6 week15 OT DIST ? 2 SCHOOL VACATIONweek16 OT DIST ? SCHOOL VACATION

week17 OT DIST 4

may-17week18 OT IN-CLASS 6

week19 OT DIST 2

week20 OT DIST 2

week21 OT IN-CLASS 6

MID-TERM ASSESSMENTVAR EUROPE DAYS PREPARATION

week22 OT DIST 2

june-17week23 OT IN-CLASS 6 VAR EUROPE DAYS PREPARATION

week24 OT DIST 2

week25 OT DIST 2

week26 OT IN-CLASS 6 VAR EUROPE DAYS PARTICIPATION

jul-17week27 OT IN-CLASS 6

week28 OT DIST 2

week29 OT IN-CLASS 6

week30 OT DIST 2

week31 OT DIST 2

aug-17

sept-17week36 OT IN-CLASS 6

week37 OT DIST 2

week38 OT IN-CLASS 6

week39 OT DIST 2

oct-17week40 OT DIST 2

week41 OT IN-CLASS 6

week42 OT DIST 2

week43 OT IN-CLASS 6

week44 OT DIST 2

nov-17week45 OT IN-CLASS 6

week46 OT DIST 2

week47 OT IN-CLASS 6

week48 OT DIST 2

dec-17week49 OT IN-CLASS 6

week50 OT IN-CLASS 6

jan-18week1 OT IN-CLASS 6

week2 OT DIST 2

week3 OT DIST 2

week4 OT IN-CLASS 6

week5 OT DIST 2

feb-18week6 OT DIST 2

week7 OT IN-CLASS 6

week8

OT DIST 2

week9 OT? IN-CLASS? 6 SCHOOL VACATION

march2018

week10 OT? IN-CLASS? SCHOOL VACATION

week11 OT DIST 2

week12 OT DIST 2

week13 OT IN-CLASS 6 EVALUATION ASSESSMENT

342

Co.N.S.E.N.So PROJECT: PROVISIONAL TIMETABLE BY WEEKWeeks in yellow must be determined with the nurses.

PLACE

Training takes place in the training room provided by the Departmental Council of the Var inGrimaud, over 6 hour days.APPENDICES

Appendix 7: Training programme in Slovenia

Problem definitionCommunity Health care across the globe as well as in Slovenia is rapidly and intensivelydeveloping. With the aging of the population (longer life expectancy) the incidence ofchronic non-communicable diseases in people aged 65 years and over is increasing, and thecommon needs of the elderly, assessed according to elderly frailty, are discussesprogressively. Nursing healthcare in Slovenia is organized on the basis of the WHO(Community AN Family Nurse) model, allowing preventive action in the field of elderly carein the home environment with a view to early detect risk factors for CND and elderly frailty.Preventive action is also aimed at the timely creation of social networks for the elderly,which, in turn, offer a longer and better quality of life in the home environment and, aboveall, support for family members who care for the feeble elderly. Nurses’ preventive activityfor the elderly in the home environment is based on extensive anamnestic data, used by anurse for an integrated and individually oriented health care, which provides support to thepatient and his family in changing lifestyle habits in terms of maintaining health, diseasecontrol or peaceful death. The community and family nurse also acts as a social networkcoordinator, creating it individually, according to the identified needs of the patient. In theframe of the undergraduate education the nurse acquires insufficient knowledge to carry outthis type of patient care, that is why it is necessary to design special areas of care for thetreatment of the elderly at home.The basic aim of the proposed training program is to further educate nurses in health carefor the elderly in community nursing. With the new in-depth knowledge specialized nurseswould be able to operate independently in the community, family and individually with thepatient. Training participants will gain in-depth knowledge in the field of identification of riskfactors, support in changing lifestyles, recognition of elderly frailty signs and response totheir occurrence, ability to form social networks and equal participation in it for the welfareof the elderly.Undergraduate nursing programmes offered in the European Union should be designedtaking into consideration the following documents: The International Directive 2005/36 / EC;the EFN guidelines for implementation of Article 31 on the mutual recognition ofprofessional qualifications, Brussels 2015; the Nursing and Midwifery Council, the Standardsfor registered nurses’ competences; the International Directive 2013/55 / EU (which replacesthe Directive 2005/36 / EC) – the Directive on recognition of professional qualifications.Slovenian higher education institutions offering nursing programmes have already launchedthe redesign of their study programmes, taking into account some additional documents:the Criteria for Accreditation and external evaluation of higher education institutions andstudy programmes within the National Agency for Quality Assurance in Higher Education inthe RS (NAKVIS, 2014), the Criteria for credit evaluation of study programmes under ECTS(2010); the Resolution of the National Programme for the Development of Higher Education2011-2020; the Principles of professional ethics (Code of Nursing and Care Ethics in Slovenia,2014); National demands for nursing personnel and Strategy of Health Care Development inSlovenia for the period 2011-2020 (Ministry of Health, 2012). Resulting from these datagraduate nurses in Slovenia will demonstrate acquired general competences in the fields of:Culture, ethics and values The promotion and respect for human rights and diversity in the light of physical,psychological, spiritual and social needs of autonomous individuals, taking into account their

opinions, beliefs, values and culture, and international and national professional codes ofethics, as well as the ethical aspect of the provision of health care; guaranteeing the right toprivacy and confidentiality in medical treatment.Taking responsibility for their own careers and identify limitations in the scope of their ownpractices and competencies.

Health promotion and prevention, guiding and educationThe promotion of healthy lifestyles, preventive measures and care for their own health bystrengthening the authority to promote health and improve the behavioral and therapeuticcompliance.Individual health care and the well-being of individuals, families and groups in health care,ensuring their safety and promote their autonomy.Integration, promotion and application of theoretical, methodological and practical skills,enabling the promotion and development of health care in long-term care, serious diseases,and in a situation of dependence and to assist the individual to maintain personal autonomyand relationship with the environment in health or disease.

Decision makingThe ability to criticaly think and use a sistematic spproach in problem solving and decisionmaking in health care in the context of professionalism in the delivery of health care.Implementation of the measures after a preliminary identification and analysis of problems,which facilitate finding the best solution for the patient, family and community, achievinggoals, improve resoults and maintain the quality of work.

Communication and team workThe ability to fully communicate, interact and work effectively with colleagues on aninterdisciplinary level and on the therapeutic work with individuals, families and groups.Delegating activities to others depending on their abilities, fitness level, competence andlegal basis.The indipendent use of electronic medical records documenting assessments of nursing,nursing diagnoses, interventions and outcomes, based on the comparable classificationsystems for nursing and nursing taxonomies.The independent acquisition, use and exchange of information between patients and healthcare professionals in health care facilities and social environment.The ability to independently, in a coordinate way take care of patients and workinterdisciplinarily towards a common goal of providing quality health care and patient safety.

Research, development and managementImplementation of scientific results into practice, supported by evidence.Consideration of equity and sustainability principles in medicine and aspiration to a rationaluse of resources.Adapting leadership styles and approaches to various situations that arise in nursing. Topromote and maintain a positive image of nursing.

NursingDemonstrating sufficient knowledge and skills to ensure professional and safe health care,adequate for the needs of individuals, families and groups / communities for which the

nurse is responsible, taking into account the development of scientific and technicalknowledge, as well as the requirements of quality and security, adopted in accordance withregulations and rules of the professional conduct.The ability to self assesment, assessment, planning and provision of integrated, personalizedcare, which focuses on health resoults, obtained by evaluating the impact of the situation,the environment, and the provided medical care, as well as through the guidelines forclinical care.The guidelines describe the processes for determining nursing diagnoses, perform healthcare and making recommendations for further care.Understanding and implementing the theoretical and methodological foundations andprinciples of nursing and the use of emergency measures based on scientific evidence andavailable resources.The independent establishment of the assessment mechanisms and the processes forcontinuous quality improvement in health care in relation to the scientific, technical andethical development.Understanding the social and cultural frameworks in the behavior of individuals and tocomply with them and their impact on the health of individuals within their cultural socialcontext.Understanding the importance of health care systems, which focus on individuals, familiesand groups and simultaneously evaluating their effects.Appropriate and timely responses to unexpected and rapid changes in the situation.Independent implementation of effective measures in emergencies or in case of natural andother disasters, which ensure the maintenance of life and its quality.

The above mentioned general competencies are required for nurses entering postgraduateeducation aimed at acquiring specific competencies needed for elderly care in the homeenvironment.Adopting the ICN competencies for community and family nurses (2002) we summed up thespecific competences of community and family nurses as follows:

Coordinating a territorial project Researcher: Identifying practice problems and seeking answers and solutions through

scientific investigation alone or in collaboration, early detection and management offrailty in older people,

Identifying the needs an nursing problem of the elderly, their families and thecommunities in which they live, early detection and management of frailty in olderpeople, Evaluate the situation of the elderly in the home environment

Health promotion and educator for elderly and families formally or informally abouthealth and illness and acting as the main provider of health information,

Care provider and supervisor: Providing direct care and supervising care given byothers, including family members, nursing assistants and other professionalsaccording to the needs for the elderly,

Elderly and Family advocate: Working to support elderly and families and speaking upon issues such as safety and access to services,

Case finder and epidemiologist: Tracking disease and playing a key role in diseasesurveillance and control.

Manager and coordinator: Managing, collaborating and liaising with family members,health and social services and others to improve access to care.

Counsellor: playing a therapeutic role in helping to cope with problems and toidentify resources, establishing the therapeutic relationship.

Consultant: Serving as consultant to elderly and families and agencies to identify andfacilitate access to resources.

Environmental modifier: Working to modify, for example, the home environment sothat the disabled can improve mobility and engage in self-care.

According to the preliminary education carried out by nurses at the undergraduate academicprogram, we anticipated the content, which will deepen the knowledge and skills of nursesin the area of community nursing care, nursing care of the elderly, integration andcoordination of social networking, which is created to support the elderly in the homeenvironment. This will provide additional input to the planned competencies. The programof education in Slovenia takes the form of lifelong education. We divided it into five phases:

Initial five-day training for all partners (45 hours), 4 months in-depth training (811 hours, including participants’ individual work), One year e-learning (1 January 2017- 31 December 2017), One year clinical training with home visits and Training on the topic of social entrepreneurship

Table 2 presents the contents of the second part of education – a four month period of in-depth training (811 hours, including participants’ individual work)Table 2: Substantive overview of the in-depth training for Co.N.S.E.N.So. nurses

Planned topics for the following three phases are in the pipeline:

a one-year e-learning (1 January 2017 - 31 December 2017), including contents on ahealthy lifestyle, management of chronic non-communicable diseases, palliative care,use of NANDA nursing

diagnoses and NIC and NOC classifications of interventions and outcomes of healthcare treatment. Through the e-classroom nurses will have a chance to meet thestakeholders who can contribute to the creation of the key social networks for thehealth and social support for the elderly and their families in their homeenvironment.

a one-year clinical training with home visits nurses will carry out according to theproject instructions.

Training on the topic of social entrepreneurship, which will be implemented in theform of workshops and advice on the preparation and realization of the participantsin the project for self-employment.

Completion of education:

The training will be completed with a certificate stating the number of training hours, afterthe completion of an exam and preparation of a professional article.

Table 2: Contents of the second part of education – a four month period of in-depth trainingContents to support the implementation of health education and interviews withthe users

Contact hoursIndipendentwork

1. Specific nursing care for the elderly 20 202. Communication with the elderly: relationship building, motivational interview,feedback, giving information

5 20

3. Changing of life-style in relation to the role of health literacy 5 204. Intercultural issues in the elderly treatment 5 205. Nutrition of the elderly 5 206. Prevention measures for cancer diseases prevention 5 207. Use of Hendling in dealing with the elderly and delibitated 5 208. Basics of Ergonomics and the elderly living, workshop 5 20Home visits procedure and cooperation with social networks offering support to theelderly 1. Presentation and instructions for use of process based working methods, nursingdiagonses and activities to carry out home visits in the frame of the project

5 20

2. Identification of elderly needs and evaluation of treatment effects 5 202. Identification of the elderly mobility needs and needs to adapt the livingenvironment

5 20

3. Training for the first visit of the elderly in their home environment 5 204. Training for nursing care planning – nurse activities 5 205. Training for subsequent visits 5 206. Training for the final visit in the frame of the CO.N.S.E.N.SO model 5 207. Establishing contacts and relationships with the elderly social networkstakeholders in the frame of the CO.N.S.E.N.SO module

5 20

8. Use of IT for anamnestic data collection 5 209. Protection of personal data in the CO.N.S.E.N.SO model 5 20Specific contents related to care of the elderly in the home environment1. Dementia and presentation of the Spominčica association 5 202. Mental disorders and dependency of the elderly 5 202. Elderly incontinence 5 203. Elderly wound care 5 204. Treatment of patients with chronic diseases at primary health care level 5 205. The role of reference clinics and CINDI programme workshops in elderly care atprimary health care level

5 20

6. Presentation of medical-technical aids and patients’ rights 5 207. Strategies of health promotion in the elderly family community 5 208. Alternative and complementary approaches to treatment : dangers and benefits 5 209. Violence against the elderly in the home environment 5 20Joint start with a short presentation of guidelines for health and social care of theelderly in their home environmentIntroductory training with a focus on the elderly community health care and presentation ofthe conceptual model Community and family nurse for elderly (from 27 June till 1 July 2016 inIzola)

46 50

201 610